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%^j< NT ' 
 
 
 
 
A
PRACTICAL SURGERY,
                 containing  Jfl&J&tfnC?*
A COMPLETE EXHIBITION OF THE PRESENT STATE
             OF THE
 PRINCIPLES AND PRACTICE
                 OF
           SURGERY,
COLLECTED FROM THE BEST AND MOST ORIGINAL SOURCES OF
            INFORMATION,
    'AND ILLUSTRATED BY CRITICAL REMARKS.
         BY SAMUEL^COOPER,
MEMBER OF THE ROYAL COLLEGE OF SURGEONS, LONDON, AND AUTHOR OF THE
       " FIRST LINES OF THE PRACTICE OF SURGERY."

  WITH NOTES AND ADDITIONS,
     BY JOHN SYNG DORSEY, M. D.
ADJUNCT PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA^ &C.
IN TWO VOLUMES.
SECOND AMERICAN
r,AlliN ENLATlOfiJkLONDON EDITION.
             PHILADELPHIA.     s

PUBLISHED BY II. & T. KITE, JOHNSON &? WARNER, M. CAREY, I. PIERCE, S. W. CON HA II,
          B. C UUZBY, E. PAUKER, AND A. SMALL.
1816. 
 
A  DICTIONARY
PRACTICAL   SURGERY.
>»®»<
    HEMATOCELE, (from ce/^«e, blood,
      and jmjAjj, a tumour.)   This is a
swelling of the scrotum, or  spermatic
cord,  proceeding  from, or caused by,
blood.
  A distinction of the different kinds of
hematocele, though not usually made, is
absolutely necessary toward rightly un-
derstanding the  disease;  the  general
idea, or conception of which, appears to
Mr. Pott  to be somewhat erroneous, and
to have produced a prognostic which is
ill-founded, and hasty.   According to
this eminent surgeon, " the disease, pro-
perly called hxmatocele, is of four kinds;
two of which have their seat within the
tunica vaginalis testis; one within the
albuginea; and the fourth in the tunica
communis, or common cellular mem-
brane, investing the spermatic vessels.
  " In passing an instrument, in order to
let out the water  from an hydrocele of
the vaginal coat, a vessel is sometimes
wounded, which is of such size, as  to
tinge the fluid pretty deeply at the time
of its  running out; the orifice  becoming
close,  when the water is all discharged,
and a plaster being applied, the blood
ceases to flow from thence, but insinuates
itself partly into the cavity of the vaginal
coat, and partly into the cells of the dar-
tos ; making, sometimes, in the space of
a few  hours, a tumour nearly equal in
size to the original hydrocele.  This is
one species.
  " It sometimes happens, in tapping an
hydrocele, that although the fluid dis-
charged by that operation be perfectly
clear  and limpid,  yet, in  a very  short
space of time, (sometimes in a few hours)
the scrotum becomes  as large as it was
before, and palpably as full of  a  fluid.
If a new puncture be now made, the dis-
charge, instead of being  limpid, (as be.
    Voi. II
fore) is now either pure blood, or Very
bloody.  This  is  another species: but,
like the preceding, confined to the tunica
vaginalis.
  " The whole vascular compages of the
testicle is sometimes very much enlarged,
and at the same time rendered so lax and
loose, that the tumour produced thereby
has, to the fingers of an examiner, very
much the appearance of a swelling com-
posed of a mere  fluid, supposed to be
somewhat  thick  or viscid.  This is in
some measure a deception; but not total-
ly so : the greater part of the tumefaction
is caused by the loosened texture of the
testis; but there is  very  frequently a
quantity of extravasated blood also.
  " If tliis be supposed to be an hydros
cele, and pierced, the discharge will be
mere blood.  This is a third kind of he-
matocele ;  and very different, in all  its
circumstances, from the two preceding:
the fluid is shed  from the vessels of the
glandular part of the testicle,  and con-
tained within the  tunica albuginea.
  " The fourth consists in a  rupture of,
and an effusion of blood from, a-branch of
the spermatic vein, in its passage  from
the groin to the testicle.  In which case,
the extravasation  is made into the tunica
communis, or cellular  membrane invest-
ing the spermatic vessels."
  Each of these  four, Mr. Pott says, he
has seen so distinctly, and perfectly, that
he has not the smallest doubt concerning
their existence, and of their difference
from each other.
  " The tunica vaginalis testis, (he con-
tinues) in a natural and healthy state, is
a membrane, which, although firm, is of
no great thickness; it is white, or rather
of a reddish white colour; and its blood-
vessels are (in a healthy state) no more
apparent to the eye, than are those of the
    A 
HEMATOCELE
  tunica albuginea:  bt.t when it  has  been
  long  or much distended, it thereby be-
  comes thick, and tough; and the vessels
  (especially those of its inner surface) are
  sometimes so large, a9 to be very visiole,
  and even varicous.  If one of these lies in
  the way of the instrument, wherewith the
  palliative cure is  performed, it is some-
  times wounded ; in which ca"e, as I have
  already observed,  the  first part of the
  serum which is discharged, is pretty deep-
  ly tinged with blood
    " Upon the collapsion of the membranes,
  and of the empty bag, this kind of hemor-
  rhage generally cc : s-.es, and nothing more
  comes of it.  But it sometimes  happens,
  either  from  the  toughness of the tunic,
  or from the varicous state of the vessel,
  that  the wound (especially if made  by a
  lancet) does not immediately unite; but
  continues  to discharge blood  into the
  cavity of the said tunic, thereby producing
  a new  tumour, and a fresh necessity  of
  operation."
    This is  what Mr. Pott calls  the  first
  species of hematocele,  which evidently
  consists in a wound of a vessel of the va-
  ginal turnc.
    " Upon  the sudden discharge  of the
  fluid,  from the b..g of  an over-stretched
  hydrocele, and thereby removing all coun-
  ter-pressure  against the  sides of the ves-
  sels, some of which are become varicous,
  one of them will, sometimes, without  hav-
  ing been wounded, burst. If the quantity
  of blood, shed from the vessel so burst,
  be small, it is soon absorbed again j and,
  creating no  trouble, the thing  is  not
  known*.  But if the quantity be consid-
  erable, it, like the preceding, occasions a
  new tumour, and calls for a repetition of
  the operation."  This, Mr. Pott calls the
  second species: "which, like  the first,
  belongs entirely to the vaginal coat,  and
  has no concern  either widi the testicle,
♦• or with the spermatic vessels.   In both,
  the bag which was full of water, becomes
  in a short space of time distended with
  blood;  which blood, if not carried off by
  absorption, mu't be discharged by open-
  ing the containing cyst: but in neither
  of these can castration (though  said to
  be the only remedy) be  ever necessary:
  the mere division of the sacculus, and the
  application  of  dry  lint   to its   inside,
  will, in general, if not  always,  restrain
  the hemorrhage, and answer every pur-
  pose, for which so severe a remedy hns
  been prescribed.   The other two  are in-
  deed of more consequence ;  they interest
    Hence, the last running of the water
from an hydrocele, i8 often bloody.
 cither the testicle itself, or the vessels by
 which it is supplied with blood, and ren-
 dered capable of executing its office ; and
 are sometimes not curable, but by removal
 of the part.            (
   " One of these  i« seated within the tu-
 nica albuginea of  the  testicle ;  the other
 in  the  tunica communis of its  vessels:
 they are neither of  them very frequent;
 but when they do happen, they call li>r all
 our attention.
   " If blood  be extravasatcd within the
 tunica albuginea,  or proper coat of the
 testicle, in consequence of a great relaxa-
 tion, and (.s it were, dissolution of part of
 the vascular compages of that gland, and
 the quantity be considerable, it will afford
 or  produce a fluctuation, to  the hand of
 an examiner, very like to that of an hydro-
 cele of  the tunica  v igiualis ;  allowing
 something for the  different density of the
 different fluids, and the  greater depth of
 the former from the surface.
  " If this be mistaken for  a simple hy-
 drocele, and an opening be made, the dis-
 charge  will be blood; not fluid, or very
 thin; not like to blood circulating through
 its proper vessels ; but dark, and dusky in
 colour,  and  nearly of  the consistence of
 thin chocolate (like to what is most fre-
 quently found in the imperforate vagina )
 The quantity discharged will be much
 smaller than was expected from the size
 of the tumour; which size  will not be
 considerably diminished  When this small
 quantity of blood  has  been  so drawn off,
 the testicle will,  upon  examination, be
 found to be much larger  than it  ought to
 he ; as well as much more loose and  flab-
 by ; instead of that roundness and resist-
 ance arising from  an healthy state of the
 gland,  within its firm strong coat;  it is
 soft, and capable of being compressed al-
 most flat, and that generally without any
 of that pain and uneasin-ss, which always
 attend the compression ofa sound testicle.
 If the bleeding ceases upon the withdraw-
 ing the cannula, (supposing a trochar to
 have been used) and the  puncture closes,
 a fresh accumulation of the «ame kind of
 fluid is soon made, and the  same degree
 of tumefaction is produced, as before the
 operation:  if the orifice does not close,
 the hemorrhage continues, and very soon
 becomes alarming.
  " In  the  two preceding  species, the
 blood comes from the tunica vaginalis, the
 testis itself being safe, and unconcerned ;
 and the remedy is found, by opening the
cavity of the said tunic ;  but in  this, the
hemorrhage comes frow  the substance of
the testicle; from the convolutions of the
spermatic artery, within  the tunica albu-
ginea:  the division  of the  vaginal  coat 
                  II AR

 can here do no  good;  and the incision
 made into the albuginea can only increase
 the mischief: the  testicle  is spoiled, or
 rendered useless, by that kind of altera-
 tion made in it, previous to the extrava-
 sation;  and castration  is the only cure,
 which a patient in such circumstances can
 d*pen«l upon.
  " The last species of this  disease arises
 from a burstiog of a branch of the sper-
 matic vein,  between the groin and scro-
 tum, in  what i->  generally known by the
 name of  the  spermatic process.  This,
 which is  generally produced by great or
 sudden  exertions of strength, feats of
 agility,  &c. may happen to persons in the
 best healt'i,  whose blood and juices are
 in the best order, and whose genital parts
 are free from blemish, or disease.
  " The effusion, or extravasation, is made
 into the cellular membrane,  which invests
 and envelopes the spermatic vessels,  and
 has something the appearance of a true
 hernia.   When the case is clear, and  the
 extravasated blood  does not give way to
 disculient applications, the  only remedy
 is to lay the tumour fairly open, through
 its whole length.   If the vessel or breach
 be small, the hemorrhage may be restrain-
 ed  by mere compression with dry lint, or
 by the use of styptics; but if it be large,
 and these means do not succeed, the liga-
 ture must be made use of."   {Pott's Chi-
 rurgical Works, Vol. II.)
  The bleeding point should be tied  sin-
 gly. It can never be warrantable to tie the
 whole spermatic chord, and  then perform
 castration, in a case like this,  notwith-
standing  Mr. Pott advises  this plan, in
 case the bleeding branch cannot be tied
 singly.  Discutient applications, and an
 occasional purge, will almost always dis-
 perse the swelling; and if not, opening
 it, taking out the blootl, filling the cavity
with lint, and using compression, one may
say, will  always answer.
  The best of the old-writers on Hematocele,
 are Celmis and Paulus JEgineta : Pott has
 excelled every modern one.
  H.EMOIilMAGlA.  (See  Hemorrhage.)
  H.EMORimOIDES.    (See   Hemor-
 rhoids.)
  HAUE-LIP.  {Labia Leporina.)  A  fis-
sure, or  longitudinal division of one  or
 both lips.
  Children are frequently born with this
kind of malformation, particularly of  the
 upper lip.  Sometimes the portions of the
 lip, which ought to be united, have a con-*
 sider.ible  interspace,  between them;  in
 other instances they are not much apart.
 The cleft is occasionally double, there
 being'a little lobe, or small ponion of the
 j.p, 'situated between the  ttvo •fissures.
               HAR                3

Every species  of the deformity has the
same appellation  of hare-lip,  in  conse-
quence  of the  imagined  resemblance
which the part has to the upper lip of a
hare.
  The fissure commonly affects only the
lip itself.   In many cases, however, it ex-
tends along the bones of the palate, even
as far as the uvula. Sometimes these bones
are totally wanting; sometimes, they are
only divided by a fissure.
  Such a malformation is always peculiar-
ly afflicting.  In  its least degree, it con-
stantly occasions  considerable  deformity;
and when it is more marked, it frequently
hinders infants from suckiag,  and makes
it indispensable to nourish them by other
means. When the lower Up alone is affect-
ed, which is not most frequently the case,
the child can neither retain  its saliva, nor
learn to speak, except with  the greatest
impediment.  But when the fissure per-
vades  the palate,  the  patient not only
never articulates  but very imperfectly,
but cannot masticate nor swallow, except
with  great difficulty, on account  of the
food readily getting up into  the nose.
  After these remarks, it is obviously very
important to  cure the malformation  as
soon as possible.  But as this  object can-
not be accomplished without an  opera-
tion, attended with some  degree of pain,
several  practitioners,  as Dionis, Garen-
geot, and others, have advised waiting
till  the child is four or five years old, on
the supposition,  that, at an earlier age,
the  child's  agitations  and cries  would
render the operation impracticable,  or de-
range all the proceedings taken to ensure
its success.  It is plain, however, that such
reasons are not exceedingly weighty.  A
child four or five  years old,  and, very
often, even one eight or ten  years of age,
is more difficult to manage, in this cir-
cumstance,  than an infant only  a few
months old.  There is no child, though
advanced to that age, which  has  not a
thousand  times more dread of the pain
than of the deformity, or of the inconveni-
ences of the complaint, to which  he  is
habituated; while an infant of tender years
fears  nothing, and  only feels the pain  of
the moment.
  A more rational objection is the liability
of infants to convulsions after operations,
and this has induced many excellent sur-
geons of the present day to advise post-
poning the  cure of the hare-lip, till the
child is about  two years old.  Perhaps
this apprehension, however,  does not vin-
dicate the delay.
  Mr. Sharp observes, " there are  many-
lips, where the loss of  substance  is so
great, that \ht edgss of tl./ fisstvre cannot 
4
HARELIP
be brought  together, or, at best,  where
they can but just touch ; in which case it
need not be advised to  forbear the  at-
tempt ; it is likewise forbid in young chil-
dren, and with reason, if they  suck ; but
otherwise it may be undertaken with great
safety, and even with more probability  of
-success  than  in others that are older."
(Operations in Surgery, chap. 34 )
  Le Dran has performed  the operation
on children of all ages, even on those  at
the breast.  B. Bell did it with success on
an  infant only three months old.   Muys
advises it to be undertaken as soon as the
child is six months old.  Roonhuysen ope-
rated on children ten weeks  after their
birth, and  all his contemporaries have
praised his singular dexterity and success.
This latter surgeon advises, as a step- es-
sential to the success of the operation, to
hinder  chddren from sleeping a certain
time before undertaking it, in  order that
they may fall  asleep immediately  after-
wards.   Opiates have also  been recom-
mended to ensure this occurrence.  M.
Louis is of opinion, that  the operation
done without any suture will succeed bet-
ter  on  infants,  than any  other method.
This subject, however, we shall treat of in
due time.
   All practitioners entertain the same sen-
timent  with regard to the  object of this
operation, which consists in reducing  the
preternatural solution of continuity to the
State of a simple wound, b) cutting off the
edges of the  separated parts throughout
their lcng'h,and then approximating these
parts, so as to make them continue in con-
tact until they have completely grown to-
gether.   But although such principles are
admitted by all surgeons, all are not of the
same opinion with respect to ihe method,
 which  it is best to follow in practice;
 some having recourse to sutures to keep
 the edges of the wound in contact; others
 disapproving of the plan, and believing
 that a perfect cure may always be  accom-
 plished by  means of adhesive plaster and
 a uniting bandage, so as to save the pa-
 tient a great deal of pain,  which sutures
 always occasion.
   M. Louis has been the  chief advocate
 for this method, which proscribes sutures,
 and he has pubhshed on this subject  two
 very interesting memoirs,  which we shall
 presently quote, for the purpose of inform-
 ing the reader of the reasons, on which
 this celebrated man founded his  opinion
 on this matter, and of the means which
 he employed.
   M. Louis thought that the  use  of su-
 tures,  in the  operation for the hare-lip,
 originated from a  false idea which  pre-
 vailed, respecting the na.ure of the dis-
 ease.  The fissure hi the lip having been
imprudently imputed to the loss  of sub-
stance, it was thought impossible to keep
the parts in contact, except by a suture.
  " The separation of the edges of the
fissure in the lip is only the effect of the
retraction  of the muscles, and  is always
proportioned to the extent of the cleft.
Those who have hare-lips  are capable  tj!
biinging the edges of the fissure together
by muscular action, when they pucker up
their  mouths.   On the other  hand, the
separation is considerably increased wheft
such persons laugh, and  the breach ap-
pears excessively large, after superficially
paring off its edges on both sides. Hence,
the interspace  in the hare-lip  must not
be mistaken for a loss of substance. The
truth of this is confirmed by the effects of
sticking plaster, which  has sometimes
been applied to the hare-lip, as  a prepa-
ratory  measure before the operation, and
which exceedingly lessens the separation
of the parts.
  " According to  the  confession  of  all
who have written in favour of the twisted
suture, it  seems  advisable only  on the
false idea, that the hare-lip is the  effect of
a greater or lesser loss of  substance; and
they say, positively, that we must not have
recourse to it when there is only a simple
division to be  united.  The  twisted su-
ture must then be proscribed  from the
operation  for the  natural hare-lip, since
it is proved that this malformation is un-
attended with  a loss of substance.  But
the loss of substance is but too real, after
the extirpation of scirrhous and cancerous
tumours, to which the lips are  very sub-
ject.  Yet, even in these  very cases, the
extensibility of the lips allows an attempt
to be made to  reunite the double incision,
by which  the tumour has been removed,
and it succeeds without the smallest de-
formity, when care has been taken to  di-
rect each incision obliquely, so that both
of them form, where they meet, an acute
angle, in the base of which the tumour is
comprised. It is on this occasion, that  the
means to procure an union ought to be  the
more efficacious, because the difficulty of
keeping the edges of the wound approxi-
mated is greater.   M. Pibrac has already
shewn, in his  memoir on the abuse of su.
tures, when speaking of the hare-lip, that
they are badly conceived means, and more
hurtful in proportion to the greater loss of
 substance, because the greater the inter-
 space is between the two parts, the more
fear is there of their efforts on the needles
or pins left in  the wound.  Hence, care
 has always been taken to make the dress-
 ings aid the operation of the suture. After
 this  consideration, judiciously  made by
 the partisans  of this plan, there was only
 one more step to be taken,  according to> 
HARE-LIP.
5
M. Pibrac, in order to evince the necessity
of proscribing it. The cap, or copper head-
piece, described by Verduc and Nuck, for
compressing  the cheeks;  the  clasps  of
Heister;  the strips  of adhesive  plaster,
which no author has  neglected expressly
to recommend; all this has been invented
in order to support  the parts, and keep
them from being disunited. When the su-
ture  failed, it was by these means, that
the original deformity was  corrected, to-
gether with that produced by the lacera-
tion, which would not have occurred with-
out the suture.   As, then, the dressings,
when methodically applied, are capable of
effectually rectifying the mischief of the
suture, why  should they be  considered
only  as a resource in a mere accidental
case  ?  Why should they not be made the
chief and primary means of reuniting the
lips,  even when there is aloss of substance ?
  "Nothing can be opposed to the proofs
adduced upon this point.  They are even
drawn from  the practice of those,  who
have employed sutures without  success.
Such persons themselves have furnished
the arguments in favour of the bandage
being capable  of  repairing the mischief
resulting from the twisted suture.  Prac-
titioners  can only be vindicated in em-
ploying this suture by confessing, that the
true principles  of  the art have not been
established concerning this subject."
   M Louis, with a view of perfecting our
notions on this matter, lays it down as a
fact, that, the  retraction of the  muscles
being the cause of the separation of the
edges  of the fissure,  it is not to those
edges  we are to apply the force which is
to unite them;  but that it- should be ap-
plied further to the very parts, whose ac-
tion  (the cause of the separation) is to be
impeded, and whose contraction is thus to
be prevented.  A  great many  means for
supporting the wound, only irritate  the
muscles and  excite them to action, and it
is this action which we should endeavour
to overcome.  The means for promoting a
union can only be methodical, when di-
rectly employed to prevent such action, by
an immediate  application on  the  point
where it is to be resisted.  The  facility,
with which the parts may be brought for-
ward, so as to bring the two commissures
of the lips into contact, by the mere pres-
sure of the  hands,  shews what  may  be
expected from a very  simple apparatus,
which will execute the same office without
any  efldrts, in a firm and permanent man-
ner,  and which will render sutures, unne-
cessary, the  inconveniences of which are
too  well known.
   M. Louis, after having explained the
reasons of the theory, on which he found-
ed his method, relates several cases, taken
either from his own practice, or that  of
others, to illustrate its advantages.   He
details the history of twenty cases,  in
which his plan perfectly succeeded, both
in accidental  hare-lips, with considerable
loss of substance, and in natural ones.  In
most of these instances, however,  it was
thought proper to assist the bandage with.
one stitch at the extremity of the fissure,
close to the vermilion border of the lip,
for the purpose of keeping the parts se-
curely on a level.
  Notwithstanding  the operation as  per-
formed with the twisted suture, is opposed
by an authority of ..such weight as that of
M. Louis, still it is the one most common-
ly practised. Few practitioners doubt that
a hare-lip may be cured by means of ad-
hesive plaster, and uniting bandages, quite
as perfectly as by a suture; and all readily
allow, that the first of these methods,  as
being more simple and less painful, would
be preferable to the latter one, if it were
equally sure of succeeding.  But it is con-
sidered far more uncertain in its effect.
To accomplish a complete cure, the parts
to be united must be maintained in  per-
fect contact, until  they  have contracted
the necessary adhesion ; and how can we
always depend upon a bandage keeping
them from being displaced ?  What other
means, besides a suture, affords in  this
respect such perfect security ?
   We shall not take upon us to  decide
which of these two  methods  is the best,
contenting ourselves with explaining the
mode of proceeding in both,  and leaving
it for surgeons to determine, by their own
experience, and  the  evidence of facts,
which one merits the difference.  First, of
the ancient plan.
   Having placed the patient  in a  conve-
nient situation,  the first thing is to ex-
amine whether there is any adhesion of the
lip to the gum ; and, if there be one,  to
divide it with  a knife.   Some  authors
{Sharp) recommend always dividing the
frenulum, which attaches  the lip to the
gum ; but,  when  the  hare-lip is at some
distance from this part, and will not be in
the way in the operation, there is no need
of dividing it; but, when the frenulum is
situated in the centre of the division, it is
clear that, in operating,  we  must neces-
sarily  include  it in  the incision, and it
must be divided before-hand, taking  care
not to encroach too much upon the gum,
lest the alveolary process should be laid
bare; nor too much upon the Up,  because
making it thinner would  be unfavourable
to its union.
   Sometimes one of the incisor teeth be-
ing  opposite the fissure, and projecting 
6                                  HARE-LfP.
  forward, must be drawn, Us  it should
  distend and irritate the parts, after they
  have been brought into contact.
    Sometimes also, but particularly in Cases
  in which there is a cleft in the bony part
  of the palate, a portion of the os maxillare
  superius forms such a projection, just in
  the situation of the fissure in the lip, that
  it would render the union very difficult, if
  not  impracticable.   In this circumstance,
  the  only plan is to cut off" the projecting
  angles of bone,  which may easily be done
  with a strong pair of bone-nippers.
    In the operation, the grand object is to
  make the wound as smooth and even a cut
  as possible, in order that it may more cer-
  tainly unite by the  first intention, and of
  such a shape, that  the cicatrix may form
  only one narrow line. The edges of the
  fissure should, therefore, never be cut oft'
  with scissars,  which always  bruise  the
  fibres which they divide, and a sharp knife
  is always to be preferred.  The best plan
i  is, either to place any flat instrument, such
  as a spatula, underneath one pirtion of
  the lip, and then holding the part stretch-
  ed and supported on it,  to cut away the
  whole of the callous edge;  or else to nold
 the part with a pair of forceps, the  under
 blade of which is much  broader than  the
 upper one: the first serves  to support the
 lip ; the other contributes also to this ef-
 feet, and, at the same time, serves as a
 sort of ruler in guiding'the  knife in an ac-
 curately straight line.  When the forceps
 are preferred, the surgeon must of course
 leave on the side of the upper blade, just
 as much of the edge of the  fissure as is to
 be removed, so that it can b cut off with
 one sweep  of the  knife.   Ti is  is to be
 done on each side of the  clefi,  observing
 the rule, to make the new wound in straight
 lines, because tne sides of it can never be
 made to correspond without
 this caution.  For instance, if
 the hare-lip had this shape, the
 incision  ef the edges must be
 continued in straight lines,  till they meet
 in the manner here represented.
 In short, tlie two incisions are
 to  be perfectly straight,  and
 are to meet at an angle above,
 in order that the whole track of the wound
 may be brought together, and united  by
 the first intention.
   Two silver pins, made with steel points
 are next to be introduced through the
 edges of the wound, so as  to keep them
 accurately in contact.  A piece of thread
 is thai to be repeatedly wound  round th^
 ends of the  pins,  from one side of the di-
 vision to the other, first transversely, then
 obliquely, from the right or left end of one
 p.n above, to the opposite end of the lower
one, &c.  Thus the thread is  made to cross
as many points of the wound as possipV
  which greatly  contributes to maintaining:
  its edges in even apposition.  It is obvious,
  that a great deal of exactness is requisite
  in introducing  the pins, in order that the
  edges of the incision may afterwards be
  precisely applied to each other.   For this
  purpose, some previously place the tides
  of the wound  in  the  best position, and
  mark with a pen  the points at which the
  pins  should  enter, and come out again.
  The  pins  ought never to extend  more
  deeply than about two-thirds through the
  substance  of the lip, and it would be a
  great improvement always to have them
  constructed a little curved, as this is  the
  course which they naturally ought to take
  when introduced.  The steel points should
  also admit of being easily taken off, when
  the pins have been applied; and, perhaps,
  having them to screw of! and on  is l\\e
  best  mode, as removing them in this way
  is not so likely to be attended with any
  sudden jerk, which might be injurious to
  the wound, as if they were made to pull off.
  The pins may commonly be safely removed
  in about four days, after which the support
  ofsticking-plasier will be quite sufficient.
   The process  we have just been describ-
 ing,  is what is well known by the name of
  the twisted suture.
   it is worthy of attention, that this suture
 is applicable  to other  surgical cases, in
 wh.ch the grand object is to heal some fis-
 tula or opening, by the first intention.  Mr.
 Sharp says, iii» of great service in fistula of
 the urethra, remaining after the operation
 for the stone,  in which c.se the callous
 edges may be cut off; and the lips  of the
 wound h<-ld together by the above method.
   What has hitherto been stated, refers to
 the most s:mple form of the hare-lip, viz.
 to that wh.ch  presents  only  one fissure!
 When there are two clefts, the cure is ac-
 complished on the same principles ; bui, it
 is more difficult of execution  ; indeed  so
 much so,  that the old surgeons, until the
 time of Heistei, have almost all regarded
 the operation for the double  hare-lip  as
 impracticable, though they have described
 it, directing us to operate on each fissure,
just as if there were onlv one.  M  de la
 Faye, however,  performed this operation
 with success, as may be learnt in'the Me-
 moires de I Acad, de Chirurgie, Tom  4. 4to
 But, we are indebted to M.  Louis for hav-
 ing obviated all the difficulties, by simply-
 proposing to do the  operation at two times
 and to await the perfect cure of one of the
 fissures,  before  undertaking  that of the
other.  Heister seems to have  conceived ■,
R milar idea, about  the same time, but lie
never  put  it in practice,  nor did he even
positively  advise it.
  In cutting off the edges of the fissure,
the incisions must be carried to the upper
part of the lip; and even when the fissure 
HARE-LIP.
?
does not reach wholly up the lip, the same
thing should be done ; for, in this manner,
the sides of the wound will admit of being
applied together more uniformly, and the
cicrti ix will have a better appearance. We
should also not be too sparing of the edges
which are to be cut off. Practitioners, says
M Louis, persuaded that the hare-lip was
a division with loss of substance, have in-
variably advised the removal of the callous
edges. But, in the natural hare-lip there is
no callosity; the margins of the fissure are
composed, like those of the lip itself,  of a
pulpy, fresh-coloured, vermilion flesh, co-
vered with  an exceedingly delicate  cu-
ticle.  The  whole of the pari having this
appearance, must be taken  away, even
encroaching a little way  on the true skin.
At the  lower part of the fissure, towards
the  nearest commissure, a rounded  red
substance is commonly situated, which  it
is absolutely necessary  to include .n  the
incision.  Were this neglected, the union
below would be unequal, and, through an
injudicious  economy, a degree of deform-
ity would remain, which  is  always  un-
pleasant,  when it  can be avoided.  The
grand object, however, is to make the two
incisions diverge at  an  acute angle,  so
that the edges may be put into reciprocal
contact their  whole length,  without the
least inequality.
   M. Louis used  to  operate  as follows :
the patient  being seated in a  good light,
-his head is to be supported on an assist-
ant's breast, who, with the fingers of both
hands,  pushes the cheeks forward, in or-
der to bring the edges of the fissure near
to each other.   These are to be laid on a
piece of pasteboard, which is to be put
between the jaw and lip, and be an  inch
and a  half long,  from twelve to fifteen
lines broad, and at most one line thick.
The  upper end should be rounded, by-
flattening the corners.  To facilitate the
 incision, the lip is to be stretched  over
 the pasteboard, the operator  holding one
 portion over the right with the thumb and
 index finger of the left hand, while the
 assistant does the same thing on the left
 side.  Things being thus disposod, the
 edges  of the hare-lip are to be cut off
 with two sweeps of the bistoury, in two
 oblique lines,  forming an  acute angle
 above the fissure.
   For. a long while  scissars were prefer-
 red to  a knife, for cutting off the edges of
 the hare-lip;  but,  they are now very ge-
 nerally  disused for this purpose.   The
 pinching and bruising,  which result from
 the action of the two blades, in overlap-
 ping each other, are deemed obstacles to
 the union of the sides of the  wound; for,
 the  bruised  fibres must necessarily sup-
 purate-,  and, slignt as this  may be, the
cure is at least retarded by it.  Let not
practitioners be led by Mr. B. Bell's stat-
ing,  that in one instance he  cut off" one
side  of the fissure with a knife, and the
other with scissars;  that the latter cut
produced least pain, and that on this side
there was no  more swelling nor inflam-
mation than on the opposite one.
  The pins should be introduced  at least
two-thirds of the  way through the  sub-
stance of the  lip, lest a furrow should re-
main on the  inside of the part,  which
might  prove  troublesome,  by allowing
pieces of food to lodge in it.  There  is,
however, a stronger reason for attending
to this circumstance, viz. the hemorrhage
which may take place when it is neglect-
ed.  The bleeding almost always ceases,
as soon as the edges of the  wound have
been brought together by means of the
suture,  when  the  pins  are  properly
placed; but, when they have not been in-
troduced deeply enough,  the posterior
surfaces of the incisions not been applied
to each other, the blood may continue to
run into the mouth, and give the surgeon
an immense  deal of trouble.  In  the me-
moir written  by Louis,  there is a history
of a case, in which  the patient  died in
consequence  of such an accident.  Persons
who  had undergone  the operation^ were
always advised  to  swallow their spittle,
even though  mixed with blood, in order
to avoid disturbing the wound, by getting
rid of it otherwise.  In the case  alluded
to, the patient, who had been operated
upon  for a cancer which he had in the
lip,  swallowed the blood as he had  been
directed to do, and  he bled so profusely
that he died.  On the examination of the
body, the stomach, and  small intestines
were  found  full  of  blood.   •« This de-
plorable case,"  says the illustrious author
who relates  it,  "deserves to be recorded
for pubic  instruction, for the purpose of
keeping alive the attention of surgeons
on all occasions,  where, in  consequence
of any operation whatsoever, there is rea-
son to fear any bleeding in the cavity of
the  mouth.   Platner is the only  writer,
 who,  as far as 1 know, foresaw this k.nd
 of danger.  The bleeding from the edges
of the wound stops of itself, (says he) as
 soon as they have been brought into con-
 tact,  and  stitched together; but, care
 must be taken that  the patient does  not
 swallow the blood,  which  might make
 him vomit, or else suffocate him.   Hence,
 his  head  should be  elevated, that  the
 blood may escape externally, a precaution
 more particularly necessary in regard to
 voung children."
 '  Having described the mode of operat-
 ing for the hare-lip, as approved of by the
 generalitv of practitioners,  and  detailed 
8                               HARELIP
 every thing which seemed material, we
 have  now  only to describe the method
 which M, Louis adopted.  His sentiments
 respecting several particular points of the
 operation, have been already stated ; and
 an account of the means which he em-
 ployed,  in lieu of the twisted suture, for
 uniting  the edges of the wound, is all
 that we  have to offer farther on the pre-
 sent subject.
   Different authors, as already mention-
 ed, have devised bandages for supporting
 the two  portions of the divided lip, and
 lessening the pressure which they make
 against  the pins designed  for  uniting
 them.  Franco  and Quesnay,  in parti-
 cular, have described two  kinds, which
 .have been considered very well calculated
 for this object; and these means were not
 only  employed as auxiliary,  but even
 sometimes as curative ones, when it was
 impossible to use needles. To such band-
 ages, too complicated and too uncertain,
 in their effect, M. Louis prefers a simple
 linen roller, one  inch wide, three  ells
 long,  and  rolled up into  two unequal
 heads.  He begins with applying the body
 of tli is bandage to the middle of the fore-
 head ; he unrolls the two heads, from be-
 fore backward, tbove  the  ears  between
 the upper part of the cartilage, and the
 cranium, in order to make them cross on
 the nape of the neck, and then be carried
 forward  again.   The assistant,  who sup-
 ports the head, and pushes forward the
 cheeks, must lift up the ends of his fin-
 gers, in the  place of which, on each side,
 a thick compress is to be put.   This be-
 ing covered,  and pushed  from behind
 forward, by the roller,  will constantly
 perform  the office of the assistant's fin-
 ge. .,  who is to continue to support the
 apparatus,  until it is all completely ap-
 plrd.  The longest of the  two  heads of
 the n Her, being slit in two places near
 the lip, presents  two parallel openings;
 the remnant of the shortest one is divided
 into two parts, as far as  its end.  The
 two little narrow bands, in which  it ter-
 minates,  must be  passed  through  the
 openings of the former, and made to cross
 upon the middle of the lip.   The ends of
 the roller, being carried from before back-
 ward, are then  to be made to cross again
 on the nape of the neck, where the short-
 est is to end.  The remainder of  the long
 one is  to be employed in m king  turns
 round  the head.  This bandage may be
 rendered much more stable, bv a piece of
 tape, wh.ch  is to pass the forehead, over
 the sagittal suture, and be pinned at each
 end to  the circumvolutions of the roller;
while a second piece of tape is to cross
tne hrstone at the top of the head, and
 also to be attached, at its extremities, t6
 the uniting bandage, and the compresses,
 placed under the  zygomatic  arches,  for
 the purpose of pushing  forward  the
 cheeks.
   This bandage is extremely simple, and
 would promise  great  advantages, even if
 its success  had not been already proved
 by the cures which it  has effected  under
 the hands of its inventor, and several other
 surgeons, who have employed it, in con-
 sequence of his recommendation.  Per-
 haps, if it has not been equally successful
 With others, this is rather owing to  the
 defective manner of applying,  than to any
 fault in the plan itself.  However it may
 be, it is much to be wished that this means
 were  sufficiently certain in  its effect, to
 become more generally adopted, so that
 the suture might be relinquished.
   All  that we have said concerning  the
 operation for the hare-lip, is  equ lly appli-
 cable, not only to the treatment of cancer
 of the lip, but  also to that of accidental
 cuts,  or lacerations, of this part, from any
 cause whatsoever.  We shall only remark
 that,  in  a recent wound, all  the duty of
 the surgeon is to have recourse  immedi-
 ately, either to the twisted suture,  or the
 uniting bandage.
   In  cases,  in Which the  fissure affects
 the bones forming the roof of the mouth,
 after  the soft parts have been united in
 the manner above related, the bones, and
 other separated parts, are ordinarily ob-
 served to become approximated, and na-
 ture thus corrects, more or less, this kind
 of deformity.   But  this  does  not always
 happen, and when  these parts remain so
 considerably separated,  as to obstruct
 speech and deglutition, or cause any other
 inconvenience, a plate of gold or  silver,
 exactly adapted  to the arch of the palate,
 and steadied  by  means of a  piece  of
 sponge, fixed to its convex side, and in-
 troduced into the cleft, may sometimes
 be usefully employed.  When  the sponge
 is of  suitable size,  and  very dry, before
 being  used,  it  will be  swelled by  the
 moisture of the adjacent  parts,  which
 alone  will be sufficient, in many cases, to
 keep  it in its situation,  so  as  greatly to
 facilitate speaking and swallowing.  Some-
 times,  however, the fissure  is so shaped,
 that the  sponge cannot  be  fixed  in it:
 this principdly  happens  when the open-
 ing widens very much, as it approaches
externally.   In such  cases  it  has been
proposed to  fix a plate of gold, by means
of  springs,  made  of the  same metal,
so  constructed  as  to  fit  the  cavity;
but, no contrivance seems  yet to have
answered.
  On the subject of the hare-lip, consult 
HEAD.
8
 JS. Bell's Surgery, Vol. 4- /leister*s Surgery.
 Le Dran's Operations; Sharp's Operations;
 Latta's Surgery,  Vol. 2 ;  L' Encyclop6die
 Mitliodique,  Purtie  Chirurgicale,  Art.
 Bee. de Lievre.   The Observations of M.
 Louis,  in M6m. de  CAcad. de  Chirurgie,
 Tom. 4. in Ato. De la Medecine Opiratoire,
 par Sabatier, Tom.  3.  (Euvres. Chirurgi-
 cales  de  Desault,  par  Bichat, Tom.  2.
 Traits des Operations de Chirurgie, par A.
 Bertrandi,  Chap.  19.  Richter's  Anfangs-
 grunde der   IVandarzneykunst,  Bund 2.
 Kap. 7. Richerand's JYosographie Chirur-
 gicale,  Tom. 3. p. 245, &c.  Edit. 2.   Las-
 sus, Pathologie  Chirurgicale, Tom.  2, p.
 451, &c. Edit. 2.

          HEAD,  injuries or.

   Mr.  Pott: remarks, that, though  the
 scalp be called the common tegument of
 the head, yet, from the variety of parts of
 which it  is composed, from their  struc-
 ture, connexions, and uses, injuries done
 to it by external violence, become of much
 more consequence, than the same kind of
 ills can prove, when  inflicted on  the com-
 mon teguments of the rest of the body;
   Passing over incised wounds, which
 have no particularity, Mr.  Pott  proceeds
 immediately to those which, (though the
 mischief  is  originally confined to  the
 mere scalp)  yet are frequently veiy ter-
 rible  to behold, are often attended with
 alarming symptoms, and sometimes with
 danger. Lacerated and punctured wounds,
 are those referred to.  " The former may
 be reduced to two kinds, viz.  those in
 wliich  the scalp,  though  torn, or  une-
 qually divided, still  keeps  its natural si-
 tuation, and  is not  stript  nor separated
 from  the  cranium,  to any  considerable
 distance beyond the breadth of the wound;
 and  those, in  which  it is considerably
 detached  from the parts it ought  to
 cover.
  " The first of these, if simple, and not
 combined with the symptoms, or appear-
 ances of any  other mischief, do not re-
 quire any particular or  different  treat-
 ment, from what the  same kind of wounds
 require  on all other parts ;  but the latter,
 (those in  which the scalp  is separated
 and detached from the parts it ought to
 cover) are not only, by the different me-
thods in which they may be treated,  fre-
quently capable of  being  cured with a
considerable deal more or  less ease and
expedition,  but  are  also sometimes a
matter of great consequence to the health
and well-being of the patient."
  Mr. Pott makes no scruple of declaring
it as his opinion, that the preservation of
rlie scalp ought alwavs to  be attempted.
    Vol.  II.
 unless it be so torn as to be absolutely spoiled,
 or there are manifest present symptoms of
 ot/ier  mischief.  This  kind of wound is
 sometimes very terrible to  look  at, and
 they who have not been accustomed to
 see it, may be inclined to think there is
 no remedy but excision; but, Mr. Pott
 says, he has so often made the experiment
 of  endeavouring to  preserve the torn
 piece, and so often succeeded, that he
 would recommend it as a thing always to
 be attempted, even though a part of  the
 cranium should be perfectly bare.  The
 removal of it necessarily produces a larger
 sore, which must require a good deal  of
 time to heal, and must leave considerable
 deformity: the preservation of it prevents
 both.
   Here we may remark, that all practi-
 tioners now invariably avoid cutting away
 the scalp, even in the circumstances,  in
 which such practice was allowed by Pott.
 By spoiled this eminent writer must mean
 so injured  as necessarily to slough after-
 wards.   However, as  no  harm  results
 from taking the chance of its not slough-
 irisr^ which never can be with certainly
 foretold; and as the excision of the part
 is painful, and productive of no benefit,
 even if sloughing  must follow, such ope-
 ration is,  in every point of view, quite
 wrong.  With respect to other mischief,
 as a reason, the examination of the cia-
 nium, and  even trephining, never require
 any of the scalp to be cut away.  See
 Trephine.
   Let the surgeon,  therefore, always
 make the  torn piece clean from all dirt,
 or foreign  b'odies, and restore it as quick-
 ly, and as perfectly as he can, to its na-
 tural situation.
   Notwithstanding Mr.  Pott assents  to
 the employment of sutures, for uniting
 certain lacerated wounds of the scalp, we
 may state,  that the best practitioners  of
 the present  day only employ sticking-
 plaster.  Sometimes, the loosened scalp
 will unite  with  the parts from which it
 was torn and separated,  and there will
 be no other sore than what arises from the
 impracticability  of bringing  the lips  of
 the wound  into smooth and immediate
 contact, the scar of which sore must be
 small  in proportion.   Sometimes  such
 perfect re-union is not to be obtained; in
 which  case, matter will be  formed and
 collected in those places where the parts
 do not coalesce: but this does not neces-
sarily make any difference, either in the
general intention,  or in  the  event; this
matter may easily be discharged, by one
or two small openings made with a lan-
cet; the  head will still  preserve its na-
tural  covering;  and  the  cure will  be
    B 
10
HEAD.
 very little retarded  by a few small ab-
 scesses.
   In some cases (as Pott proceeds to de-
 scribe,) the  whole  separate piece will
 unite perfectly, and give little or no trou-
 ble, especially in young and healthy per-
 sons.   In some, the union will take place
 in some parts and not  in  others ;  and,
 consequently, matter will be formed, and
 require to be discharged, perhaps at se-
 veral different points; and, in some par-
 ticular cases, circumstances, and  habits,
 there will be no union  at all,  the  torn
 cellular membrane, or the naked aponeu-
 rosis, will inflame, and become sloughy, a
 considerable quantity of matter will be
 collected, and, perhaps, the cranium will
 be denuded.  But, even in this state of
 things, which does not  very often  hap-
 pen, where care has  been taken,  and is
 almost  the worst which can happen, in
 the  case of  mere simple laceration and
 detachment,  if  the surgeon will not be
 too soon, nor too much alarmed, nor in a
 hurry to cut, he will  often find  the cure
 much more feasible than he may at  first
 imagine:  let him take care to keep the
 inflammation under by proper means, let
 him have patience till the matter is fairly
 and fully formed, and  the sloughs  per-
 fectly separated, and when this is accom-
 plished, let him make a proper number
 of dependent openings for the discharge
 of them,  and   let  him  by  bandage,
 and other proper management, keep the
 parts in constant contact with each other,
 and  he will often find, that although he
 was foiled in his first intention  of pro-
 curing  immediate union, yet he will fre-
 quently succeld in this his  second; he
 w.ll still save the scalp, shorten the cure,
 and prevent the great deformity arising,
 (particularly to women) not only from
 the scar, but from the total loss of hair.
   This  union may of:en be procured,
 even though the cranium should have been
 perfectly denuded by  the accident; and,
 it is true, not only though it should have
 been stripped of its pericranium at first,
 but even if that pericranium should have
 become sloughy and cast off,  as Mr. Pott
 has often seen.
   " Exfoliation from a cranium laid bare
 by exrernal  violence, and to which no
 other injury has  been done, than merely
 stripping it of its covering, is a  circum-
 stance (says  Pott)  which would not so
 often happen, if it was not  taken  for
 granted that  it  must be, and the  bone
 treated  according to  such  expectation
 The  soft open texture of the bones of
ttiildren and  young  people, will  fre.
quently furnish  an  incarnation, which
 will cover their surface, and render exfo-
 liation quite unnecessary;  and even  in
 those of mature age, and in whom the
 bones are still harder, exfoliation  is full
 as often the effect of art as the intention
 of nature,  and produced by a method of
 dressing, calculated to accomplish such
 end, under a supposition of its being ne-
 cessary.  Sometimes, indeed, it happens
 that a small scale  will necessarily sepa-
 rate, and  the sore  cannot,  be perfectly
 healed till such separation has been made;
 but this  kind of exfoliation will be very
 small  and   thin, in proportion to that
 produced by art, that is, that produced by
 dressing the surface of the bare  bone with
 spirituous  tinctures, &c.  and when a
 wound on the head, with a sound unin-
 jured bone, denuded by accident,  shews
 a disposition to heal without /exfoliation,
 it  never can be right to covLnteract na-
 ture, and oblige her to do what  she  is
 not inclined to, and which she would ac-
 complish her purpose better without do-
 ing.
   " Small  wounds, that is,  such as are
 made by instruments,  or bodies  which
 pierce, or puncture, rather than cut^are
 in  general  more  apt to become  inflamed,
 and to  give trouble, than those which are
 larger,  and in this part particularly, are
 sometimes  attended  with so high inflam-
 mation, and with such symptoms as alarm
 both patient and surgeon."
   The  parts  capable of being hurt by
 such kind of wound, are the skin, the cel-
 lular membrane,  the expanded tendons
 of the muscles of the scalp, and the peri-
 cranium.
   " If  the  wound  affects the cellular
 membrane only, and has not reached the
 aponeurosis or pericranium, the inflam-
 mation  and  tumour affect the whole head
 and face,  the skin of which wears  a yel-
 lowish  cast, and is  sometimes thick set
 with  small  blisters, containing  the same
 coloured  serum;  it receives the impres-
 sion of  the fingers, and becomes pale for
 a moment, but returns immediately to its
 inflamed colour ;  it  is not very painful
 to the  touch, and the eye-lids  and ears
 are always comprehended in the  tumefac-
 tion,  the former of which are sometimes
 so distended, as to be closed; a feverish
 heat and  thirst generally accompany it;
 the patient is restless, has a quick pulse,
 and most commonly a nausea, and inclina-
tion to vomit.
  " Tliis accident generally  happens te
persons  of bilious habit,  and is indeed an
inflammation of the erysipelatous kind;
it is somewhat alarming to look at, but is
not often attended  with danger.   The
wound does  indeed neither look well, nor
yield a kindly discharge, while the  fever 
HEAD                                  11
contuses,  but still it has nothing threat-
ening in its appearance, none of that look
which bespeaks  internal mischief;  the
scalp continues  to adhere firmly to the
skull, and  the patient does not complain
of that tensive pain, nor is afflicted with
that fatiguing restlessness  which gene-
rally  attends  mischief  underneath  the
cranium.
  " Phlebotomy, lenient  purges, and the
use of the  common febrifuge  medicines,
particularly those of the  neutral kind,
generally remove it in a short time. When
the inflammation is gone  off, it leaves on
the skin a yellowish tint,  and a dry scurf,
which continues  until perspiration carries
them away, and upon the  disappearance
of the disease, the wound immediately
recovers a healthy aspect, and soon heals
without any farther trouble.
  " Wounds and contusions of the head,
which affect the  brain  and  its  mem-
branes, are also  subject  to an erysipela-
tous kind of swelling and inflammation;
but it is very different,  both in its cha-
racter and consequences, from the pre-
ceding.
  «' In this, (which is one of the effects of
inflammation  of the meninges,)  the  fe-
brile  symptoms  are  much higher,  the
pulse harder  and  more frequent,  the
anxiety  and restlessness extremely  fa-
tiguing, the pain  in  the head intense;
and  as  this kind of appearance is,  in
these circumstances, most frequently the
immediate precursor  of  matter forming
between the skull and dura mater, it  is
generally attended with  irregular shiver-
ings,  which are not followed by a critical
sweat, nor  afford any relief to the pa-
tient.  To-which  it maybe added, that
in the former case the  erysipelas gene-
rally  appears  within  the  first three or
four days;  whereas in the latter, it sel-
dom cornes on till several days after the
accident, when the symptomatic fever is
got to some height.  Jn the simple erysi-
pelas, although the wound be  crude and
undigested, yet it has no otlier mark of
mischief; the pericranium adheres firmly
to the skull,  and upon  the cessation  of
the fever, all  appearances become imme-
diately favourable.  In that which accom-
panies injury  done to the parts under-
neath, the wound not only has a spongy,
glassy, unhealthy aspect, but the pericra-
nium  in   its  neighbourhood  separates
spontaneously from the  bone, and  quits
all cohesion with it.  In  short, one is an
accident, proceeding from a bilious habit,
and not indicating any  mischief beyond
itself; the other is a symptom, or a part
of a disease, which is occasioned by in-
jury done  to the membranes of the brain;
one portends little «r no  ill to the patient,
and almost always ends well; the other
implies great hazard, and most commonly
ends fatally.   It is therefore hardly ne-
cessary to say, that it behoves every prao
titioner to be careful in distinguishing
them from each other.
  " If the wound be a small one, and ha9
passed through the cellular membrane to
the aponeurosis, and pericranium, it is
sometimes attended with very disagree-
able, and even very alarming symptoms,
but which arise from  a  different  cause,
and  are  very  distinguishable from what
has been yet mentioned.
  " In  this, the inflamed scalp does not
rise into that degree of tumefaction, as in
the erysipelas, neither does it pit,  or re-
tain  the  impression of the fingers of aq
examiner ; it  is of a  deep red  colour,
unmixt with the yellow tint of the erysi-
pelas ;  it appears tense, and is extremely
painful to the touch; as it is not an affec-
tion of the cellular membrane, and as the
ears  and the eye-lids are not covered by
the parts in which the wound is inflicted,
they are seldom, if ever, comprehended
in the  tumour, though they may partake
of the  general inflammation of  the skin ;
it is generally attended with acute pain
in the  head, and  such a degree of fever
as prevents sleep,  and sometimes brings
on a delirium.
  "A  patient in  these  circumstances,
will admit more free evacuations by phle-
botomy, than one labouring under an ery-
sipelas ; the use of warm fomentation is
required in both,  in order  to  keep the
skin clean and perspirable, but an emol-
lient cataplasm, which is generally  for-
bid in  the former,  may in this latter case
be used to great advantage.
   "When  the symptoms  are  not very
pressing, nor the  habit very inflammable,
this  method will prove sufficient: but it
sometimes happens that the scalp is so
tense,  the pain so great, and the symp-
tomatic fever so high, that by waiting for
the slow effect of such means, the patient
runs a risk from the continuance of the
fever,  or else the injured aponeurosis and
pericranium becoming sloughy, produce
an abscess, and render the case both te-
dious and troublesome. A division of the
wounded part by a simple incision down
to the  bone, about half an inch or an inch
in length, will most commonly  remove
all the bad symptoms, and  if it be done
in time,  will render every thing else un-
necessary."  {Pott.)
   The injuries, to which the scalp is lia-
ble from contusion,  or the appearances
produced in  it by  such general cause,
may be divided into  those  in which, the
mischief is confined merely to the scalp; 
U                                 HEAD.
  and those  in  which other parts  are  in-
  terested.
    The former, which only comes under
  our present consideration, is not  indeed
  of  importance,  considered abstractedly.
  The tumour attending it is either very
  easily  dissipated, or  the extravasated
  blood causing it, is easily got nd off by a
  small  opening   Mr.  Pott  particularly
  notices this case, on account of an acci-
  dental  circumstance,  which sometimes
  attends it, and renders it liable to be very
  much mistaken.
    " When th? scdp receives a very smart
  blow, it often happens that a quantity  of
  extravasated blood immediately forms  a
  tumour, easily  distinguishable  from all
  others, and generally  very easily  cured.
  But it also sometimes happens, that this
  kind of tumour produces to the fingers of
  an unadvised  or inattentive  examiner,  a
  sensation, so  like to that of  a /racture,
  with depression of the cranium, as may
  be easily mistaken." Now, if, upon such
  supposition, a surgeon immediately makes
  an incision into the tumid scalp, he may
  give his patient  a  great deal of unneces.
  ;->ary pain, and for that reason run some
  risk of his own character.
    "The touch is, in this case, so liable
  to deception, that recourse should always
  be had to other circumstances and  symp-
  toms, before an opinion be given.
    " If a person, with such tumour occa-
 sioned by a blow, and attended with such
 appearances, and feel, has any  complaint,
 which seems to be the  effect of pressure
 made on the brain and nerves, or of any
 mischief done to the parts within the cra-
 nium, the division or removal of the scalp
 in  order to enquire into the  state of the
 skull, is right and necessary; but  if there
 are no such general symptoms, and the
 patient is in  every respect perfectly well,
 the mere feel of something like a fracture
 will not authorize or vindicate  such ope-
 ration, since  it will often  be found, that
 such sensation  is a deception, and that
 when the extravasated  fluid is removed,
 or  dissipated, the cranium  is perfectly
 sound and uninjured.
  "The second  kind of tumour attend-
 ing the  contused scalp, viz. that which
 arises from injury done to the cranium, and
 parts within,  does so absolutely proceed
 from and depend upon such injury, as not
 to  fall under our  consideration  in this
 place at all,  but will  be  considered at
 large when we come to speak of the mis-
 chiefs dtoe to the skull and brain by col-
lision, or contusion.
  " From what has been said it appears,
that the scalp,  taken in a general sense,
 is,  when wounded or bruised, liable to
 be  affected with  four kinds of-tumour,
  each of which has a distinct cause, and
  requires, or permits, a different method
  of treatment.
    " The first does not imply any  injury
  done to  the parts within the skull,  re-
  quires no operation, and almost always is
  cured by general remedies.
    " The second, or that which is  caused
  by the spontaneous separation of the peri-
  cranium from the skull,  in  consequence
  of internal mischief, is not at first attend-
  ed with  very pressing  symptoms;  but
  whoever has observed their progress, and
  attended to their event, must know  what
  fatal and frequently irresistible evil it  is
  the forerunner of, nothing less  than the
  inflammation  and  putrefaction  of  the
  membranes of the brain,  and the  forma-
  tion  of  matter between  them  and  the
  skull; and  that  is a case which,  of all
  others, will  hast admit delay.
    "  The third* though it sometimes gives
  way  to  free  evacuation,  and lenient ex-
  ternal applications,  yet  is sometimes also
  attended  with symptoms  which are too
  pressing to wait the effect of such  reme-
 dies, and is capable of being immediately
 relieved by a division of the inflamed and
 irritated parts:  whereas  the same  inci-
 sion, made into the first kind  of tumefac-
 tion, would most probably exasperate the
 disease, and heighten the symptoms.
   "The  fourth,   consisting  of  extrava-
 sated blood, seldom requires any chirurgie
 operation; time, and the use  of the com-
 mon  diseutient  applications, (of which
 the lotio salis ammoniaci is best,) almost
 always dissipate it; and it only becomes
 of consequence, by the possibility of its
 being misunderstood and  mistreated."__
 {Pott on Injuries oftlie Head)

 2.  Effects of Contusion  on the Dura Mater
       and Parts ivithin tlie Skull.
   Mr. Pott remarks, "tliat  in  order  to
 understand rightly, and  to have a  clear
 idea of, this  kind of injury, it  is neces-
 sary to recollect, that  the  vessels of the
 pericranium, those of the  diploe, or me-
 dullary substance between  the two  tables
 of some parts of the cranium, and those
 of the dura mater within  it, do  all con-
 stantly and freely communicate with each
 other; and that  this  communication  is
 carried on by  means of innumerable  fora-
 mina, found in all plrts of both surfaces
 of the skull,  as well as at the sutures •
 that upon the freedom of this communical
 tion depends  the healthy and sound  state
 of all the parts concerned in it; and that
 from  the  interruption or  destruction of
 this proceed  most  of  the  symptoms at-
 tending violent contusions of the  head
extravasations of fluid between  the era'
mum  and  dura mater,,, inflammations of 
HEAfl.                                U
 the  said  membrane,  and simple unde-
 pressed fracture of the skull.
   " The pericranium is so firmly attach-
 ed to the outer surface of the skull, as not
 to be separable from it  without consider-
 able violence; and  when such violent
 separation is made  in a living subject
 (especially if young,) the cranium is al-
 ways seen to bleed  freely, from an  infi-
 nite  number of small  foramina.   The
 dura mater, which is a firm strong mem-
 brane, is almost as intimately attached to
 the  inside of the skull,  as the pericra-
 nium is to the outside,  and  by the same
 means, viz.  by vessels;  and  by these
 means a constant circulation and commu-
 nication are  preserved and maintained
 between the two  membranes and  the
 bones dividing them.   This, all the  ap-
 pearances  which attend the, scalping a
 living person, or the separation of  the
 skull from the dura mater of a  dead  one,
 (especially if such person died apoplectic,
 or was hanged) prove beyond all doubt;
 in the former, the blood will be seen issu-
 ing from every point of the surface of the
 cranium ; in  the latter, not only a consi-
 derable degree  of force  will  be found
 necessary to detach the sawn bone from
 the subjacent membrane,  but when it is
 removed, a great number of bloody points
 will be seen  all over the  surface of the
 latter; which points, if wiped  clean, do
 immediately become bloody again, being
 only  the  extremities of broken vessels.
 These vessels are largest at, and about
 the sutures, at which places the adhesion
 is the strongest, and the hemorrhage upon
 separation the greatest.
   " It has been thought by many that the
 dura mater was  attached to the skull,
 only  at the  sutures ;  that in  all  other
 parts it was loose  and unconnected with
 it;  and that it  constantly  enjoyed or
 performed an, oscillatory kind of motion,
 and  was alternately  elevated  and  de-
 pressed.  This idea  and  opinion were
 borrowed from the appearance which the
 dura mater makes in a living subject after
 a portion of the skull has  been removed :
 but  although it has been inculcated by
 writers of great eminence, yet  it has no
 foundation  in  truth  or nature, and  has
 misled  many practitioners in their  opi-
 nions, not only of the structure and dis-
 position of this membrane,  but in their
 ideas of its diseases.
  " The dura mater does on the internal
surface of the bones  of the cranium, the
office of periosteum, in the same manner
as the pericranium does on the  external;
 (at least they have no other:) to this it is
so firmly, and so generally attached, as to
be incapable of any, even the smallest de-
gree of motion.  The alternate elevation
 and subsidence of it, which are observable
 when  any portion of it is laid bare, are
 owing to a very different cause from any
 power in itself; neither  is, nor can ever
 be performed,  until  a piece of the cra-
 nium has been forcibly taken away; and
 consequently cannot possibly be natural,
 Or necessary.
   "By  blows,  falls, and other shocks,
 some of the larger of those vessels which
 carry on this communication between the
 dura mater and the skull are broken, and
 a quantity of blood is shed upon the sur-
 face of that membrane.  This is one spe-
 cies of bloody extravasation, and indeed
 the  only one which  can be formed be-
 tween the skull and dura mater.  If the
 broken vessels be few, and the quantity
 of blood which is  shed  be small,  the
 symptoms are generally  slight, and by
 proper treatment disappear.  If they are
 large, or numerous, or the quantity of ex-
 travasated fluid considerable, the symp-
 toms are generally urgent in proportion ;
 but whether they be  slight, or consider-
 able, whether  immediately alarming or
 not, they are always, and uniformly,  such
 as indicate pressure  made on  the  brain
 and nerves,  viz. stupidity, drowsiness,
 diminution or loss of sense, speech, and
 voluntary motion.
   " This every practitioner knows to be
 one frequent consequence of blows on the
 head.  But it also  often happens,  from
 the same  kind  of violence, thaJs*ome of
 the small vessels, which carry onthe cir-
 culation  between the  pericranium, skull,
 and dura mater, are  so damaged, as not
 to be able properly to execute that office,
 although there are none so broken  as to
 cause an actual effusion of blood.
   " Smart and severe strokes on the mid-
 dle part of the bones at a distance  from
 the sutures, are most frequently  followed
 by this kind  of mischief; the  coats of
 the small vessels, which sustain the in-
jury, inflame and become sloughy, and, in
 consequence of  such  alteration in them,
 the pericranium separates from the  out-
 side of that part of the bone,  which re-
 ceived the blow, and the dura mater from
 the  inside, the latter of which  mem-
 branes, soon after such inflammation, be-
 comes sloughy also, and furnishes matter,
 which matter being collected between the
 said membrane  and  the  cranium,  and
 having  no natural  outlet,  whereby to
 escape, or be  discharged,  brings  on a
 train of very terrible symptoms, and is a
 very frequent cause of destruction.   The
 effect of this kind of violence is frequent- ,
 ly confined to the vessels connecting the
 dura mater to the cranium, in which case
 the matter is  external to the said mem-
 brane ; but it sometimes happens, that by 
14
HEAD.
  the force either of the stroke or of the
  concussion,  the vessels which pass be-
  tween and connect  the two meninges are
  injured  in  the  same manner; in which
  case, the matter formed in consequence
  of such  violence is  found on tlie surface
  of the brain, or between the pia and dura
  mater, as well  as on the surface of the
  latter ;  or perhaps in all these three situ-
  ations at the same time.
    " The difference of this kind of dis-
  ease, from  either  an  extravasation  of
  blood, or a commotion of the medullary
  parts of  the brain, is great and obvious.
  All the complaints produced by extrava-
  sation, are, such as proceed from pres-
  sure, made on the brain and nerves,  and
  obstruction to the circulation of tlie blood
  through  the former; stupidity,  loss  of
  sense  and  voluntary motion,  laborious
  and obstructed pulse and respiration, 8cc.
  and (which  is of importance to remark,)
  if the effiteion be at all considerable, these
  symptoms appear immediately, or very
  soon after tlie accident
   " The  symptoms attending an inflamed
  or sloughy state of the membranes,  in
  consequence of external  violence,  are
  very different; they  are all of the febrile
  kind, and never, at  first, imply any  un-
  natural pressure; such  are, pain in  the
  head, restlessness, want of sleep, frequent
  and hard pulse, hot and dry skin, flushed
  countenance, inflamed eyes ;  nausea, vo-
  miting, ^or ; and toward the end,  con-
  vulsion, ^bid  delirium.    And  none  of
 these appeal- at first,  that is, immediately
 after the  accident;  seldom  until some
 days are past.
   " One set  or class of symptoms  is pro-
 duced by an  extravasated  fluid, making
 such pressure on the brain and origin of
 the  nerves, so as to impair or abolish vo-
 luntary motion and the senses; the other is
 caused by the inflamed or putrid state of the
 membranes coveringthe brain, and seldom
 affects the organs of sense, until the latter
 endof tlie disease, that is, until a con,idera-
 ble quantity . f matter is formed, which
 matter must press like anv other fluid."
   Mr. Pott next refutes the generally re-
 ceived opinion, ^hat blood shed from its
 vessels, and  remaining confined  in one
 place, will become pus; and that the mat-
 ter found  on the  surface of the dura ma-
 ter,  towards the  end 'of these cases, was
 originally extravasated blood.  Both these
 positions are false. That pure blood shed
 from  its vessels,  by means of  external
 violence,  and kept from  the air, w ill not
.turn to, or become matter, is proved  in.
 contestably by every day's experience, in
 many instances, in  aneurisms  by punc-
 ture,  in retained  menses by imperforate
 vagina, and in all ecchymoses.   True pus
  cannot be made from blood merely,  as
  may be known from the  manner in which
  all abscesses are formed, and from every
  circumstance attending suppuration ; and
  that" the matter  found on the surface of
  tlie dura mater,  after great contusions of
  the head, never was mere blood, Mr. Pott
  is as certain, as  observation and  experi-
  ence can make him.
 .   " If there be neither fissure nor frac-
  ture of the skull, nor extravasation, nor
  commotion underneath  it, and the scalp
  be neither considerably  bruised,  nor
  wounded,  the mischief is seldom disco-
  vered  or attended to for some few days.
  The first attack is generally by pain in
  the part which received the blow.  This
  pain, though beginning  in that point, is
  soon extended all over the head,  and is
  attended with  a  languor,  or dejection  of
  strength and spirits,  which are soon fol-
  lowed  by  a nausea,  and inclination  to
 vomit,  vertigo or giddiness, a quick and
 hard pulse, and an incapacity of sleeping,
 at least quietly.   A day or two after this
 attack, if no means preventive of inflam-
 mation are used,  the part stricken gene-
 rally swells, and  becomes  puffy, and ten-
 der, but not painful;   neither  does the
 tumour rise to any considerable  height,
 or spread  to  any great  extent: if this
 tumid part of the  scalp be now divided,
 the pericranium  will be found of a dark-
 ish hue; and either quite detached, or
 very easily separable from the skull, be-
 tween which and  it will be found a small
 quantity of a dark-coloured ichor.
   " If the disorder has  made  such pro-
 gress, that  the pericranium is quite sepa-
 rated and detached from the skull, the
 latter will even now be found to be some-
 what altered  in  colour  from  a  sound
 healthy bone.  Of this alteration it is not
 very  easy to convey an idea by  words,
 but it is a very  visible one, and what some
 very able writers have noticed.
   " From this time the symptoms gene- ;
 rally advance more hastily and more ap-
 parently; the  fever increases,  the skin
 becomes  hotter,  the pulse quicker and
 harder, the  sleep more disturbed,  the
 anxiety and restlessness more fatiguing;
 and to these ate  generally added irregul
 lar rigors, which  are not followed by any
 critical  sweat, and which,  instead of re.
 heving  the patient, add considerably to
 his sufferings.  If the  scalp has not been
 divided or removed, until the symptoms
 are thus far advanced, the alteration of
 the colour of the bone will be found to be
 more remarkabfe; it will be found to be
 whiter and more dry than  a healthy one;
or, as Fallopius  has very justly observed)
it will be found to be more like a dead 
HEAD.
15
bone:  the sanies, or fluid, between it and
the pericranium will  also, in this state,
be found to be more in quantity, and the
said membrane will have a more livid dis-
eased aspect.      •
  " In this  state of matters, if the dura
mater  be denuded,  it will be found to be
detached from the inside of the cranium,
to have lost its bright silver hue, and to
be, as it were, smeared over with a kind
of mucus, or  with  matter, but not with
blood.  Every hour after this period, all
the symptoms are  exasperated, and ad-
vance  with  hasty strides :  the head-ach
and  thirst  become  more  intense,  the
strength decreases, the rigors  are more
frequent, and  at last convulsive motions,
attended in some with delirium, in others
with  paralysis,  or  comatose  stupidity,
finish the tragedy.
  " If the scalp has not been divided till
this  point of  time,  and it  be done now,
a very offensive discoloured kind of fluid
will be found  lying on the bare cranium,
whose appearance will be still more un-
like  to the  healthy natural  one; if the
bone be now  perforated, matter will be
found  between it and the dura mater,
generally  in considerable quantity,  but
different in  different  cases  and circum-
stances.   Sometimes  it will be  in great
abundance, and diffused over  a very large
part of the  membrane;  and sometimes
the quantity will be less, and consequent-
ly the space which it occupies smaller.
Sometimes it lies only on tlie exterior sur-
face of the dura mater ; and sometimes
it is between it and the pia mater, or also
even on the surface  of the brain, or with-
in the substance of it.
  " The primary and original cause of all
this, is the stroke upon the skull: by this
the "vessels which should carry on the cir-
culation between the  scalp, pericranium,
skull,  and meninges,  are injured, and no
means  being used to prevent tlie impend-
ing mischief, or such  as have been made
use of proving ineffectual,  the  necessary
and mutual  communication between  all
these parts ceases, the pericranium is de-
tached from the skull, by means of a sa-
nies  discharged from the ruptured ves-
sels, the bone  being deprived of its  due
nourishment  and  circulation  loses   its
healthy appearance, the  dura mater (its
attaching vessels being destroyed, or ren-
dered unfit for their office) separates from
the inside of the cranium, inflames  and
suppurates.
  " "Whoever will attend to  the appear-
ances which the parts concerned make in
every stage of the disease,  to the nature
of tlie symptoms, the time of their access,
their progress, and  most frequent event,
will find them all  easily and fairly de-
ducible from  the one  cause, which has
just been assigned, viz.  the contusion.
As the inflammation and separation of
the dura mater, is not an immediate con-
sequence of the violence, so neither are
the  symptoms immediate, seldom  until
some days have passed; the fever at first
is slight, but increases gradually ; as the
membrane becomes more and more dis-
eased, all the febrile symptoms are height-
ened ; the formation of matter occasions
rigors, frequent and irregular, until such
a quantity is collected, as brings on deli«
rium, spasm, and death."
   Hitherto Mr. Pott has been describing
this disease as unaccompanied  by any
other, not even by any external  mark of
injury, except perhaps a trifling bruise of
the  scalp ; " Let  us now, (says this emi-
nent  surgeon,) suppose  the scalp to be
wounded at the time of the accident, by
whatever gave the  contusion ; or let us
suppose, that  the immediate  symptoms
having been alarming, a wound had been
made, in order to examine the skull.
   " In this case,  the wound will for some
little time have the same appearance as a
mere simple wound of this part, unattend-
ed with other mischief,  would have;  it
will, like that, at first discharge  a thin
sanies, or gleet, and then begin to suppu-
rate i it will digest, begin to incarn, and
look perfectly  well; but, after a few days,
all these favourable appearances will va-
nish ;  the sore will lose  its florid  com-
plexion, and granulatedssurface ; will be-
come pale, glassy, and flabby;  instead of
good matter, it will discharge only a thin
discoloured sanies ;  the  lint with which
it is dressed, instead of coming off easily
(as in a kindly suppurating sore) will
stick to all parts  of it; and the pericra-
nium, instead of adhering firmly to the
bone,  will separate from it, all round, to
some distance  from the edges.
   " This alteration  in  the face  and cir-
cumstances of the sore, is produced mere-
ly by the diseased state of the parts un-
den.cath the  skull; which  is  a circum-
stance of great importance,  in support of
the doctrine advanced;  and  is demon-
strably proved, by observing that this dis-
eased aspect of the  sore, and this sponta-
neous separation of the pericranium, are
always confined to that part which covers
the altered or  injured portion of the dura
mater, and do  not at all affect the rest of
the scalp ; nay, if it has by accident been
wounded  in  any other part, or a por-
tion  has  been removed from  any part
where no  injury has  been done to the
dura mater, no such separation will hap-
pen,  tlie  detachment  above, will always 
  correspond to Uiat below, and be found no
  where eise.
    " The  first appearance of alteration in
  tlie wound immediately succeeds the fe-
  brile attack; and as  the  febrile  symp-
  toms increase, the sore becomes worse
  and worse, that is, degenerates more and
  more from a healthy, kindly aspect.
    " Through  the whole time, from  the
  first attack of the fever, to the last and
  fatal period, an attentive observer will re-
  mark tlie  gradual alteration of the colour
  of the bone, if it be bare.  At first it will
  be found to be whiter, and more dry, than
  the  natural one; and as the  symptom*
  increase, and  either  matter is collected,
  or tlie dura mater becomes sloughy, the
  bone inclines  more and more to a kind of
  purulent hue, or whitish yellow; and it
  may also be worth while in  this place to
  remark, that if the blow was on or very
  near to a suture, and the subject young,
  the said suture will often separate in sucn
 a manner as to let through it a loose, pain-
 ful,  ill-natured fungus;  at which time
 also  it is  no uncommon thing for  the
 patient's head and face  to be  attacked
 with an erysipelas.
   " In those cases, in which the scalp is
 very little injured  by the bruise, and in
 which there is no wound, nor any immedi-
 ate alarming  symptoms or  appearances,
 the patient feels little or no inconveni-
 ence,  and  seldom makes any complaint,
 until some few days are past. At the end
 of this  uncertain time, he is  generally
 attacked by the symptoms already recit-
 ed ; these are not pressing  at  first,  but
 they soon increase to such a degree, as to
 baffle all our art:  from whence it  will
 appear, that when this  is the  case, the
 patient frequently suffers from what seems
 at first to indicate his safety, and prevents
 such attempts being made, and  such care
 from being taken of them, as might prove
 preventive of mischief.
   " But if the integuments are so injured
 as to  excite or claim  our early regard,
 very useful information may from thence'
 be  collected;  for whether "the  scalp  be
 considerably  bruised,  or whether it  be
 found necessary to divide it for the dis-
 charge of extravasated blood,  or on ac-
 count of  worse appearances, or more  ur-
 gent symptoms, the state of the pericra-
 nium  may  be  thereby sooner  and more
 certainly  known: if in the place of such
 bruise, the pericranium be found sponta-
neously detached from  the skull, liaving
 a quantity of discoloured sanies between
them under  the tumid part, in the man-
 ner already mentioned, it may be regard-
ed as a pretty  certain indication, either
that the dura mater is  beginning to sepa-
  rate in the same manner,  or that if soriif
  preventive  means  be  not  immediately
  used, it will soon suffer; that is, it will
  inflame, separate from the skull, and give
  room for a collection »of matter between
  them.  And  with  regard to  the wound
  itself, whether it was made at  the time of
  the accident, or afterward artificially, it
  is the same thing ;  if the alteration of its
 appearance be as related, if the edges of
 it s-pontaneously quit their adhesion to the
 bone, and the febrile symptoms are at the
 same time making their attack, these cir-
 cumstances will serve to convey the same
 information, ami to prove the same tiring.-
   " This particular effect of contusion is
 frequently  found  to attend on fissures,
 and undepressed fractures of the cranium,
 as well as on extravasations of fluid, in
 cases where the bone is entire; and, on
 the other hand, all these do often happen
 without the concurrence of this individual
 mischief.   All this is matter of accident;
 but  let the other circumstances be what
 they may,  the spontaneous separation of
 the altered  pericranium, in consequence
 of a  severe blow, is almost always follow-
 ed by a suppuration  between the cranium
 and dura mater; a circumstance extreme-
 ly well worth attending to in fissures and
 undepressed fractures  of the  skull,  be-
 cause it  is from  this circumstance prin-
 cipally, that the bad symptoms, and the
 hazard, in such cases arise.
   " It is no very uncommon thing for a
 smart blow on the head to  produce some
 immediate  bad symptoms,  which, after a
 short space of time  disappear,  and leave
 the patient perfectly well.  A slight pain
 in the head, a little acceleration of pulse,
 a vertigo and sickness,  sometimes imme-
 diately follow such  accident, but do  not
 continue many hours, especially, if any
 evacuation has been used.  These are not
 improbably owing to a ^ light commotion
 of the brain,  which having  suffered no
 material injury thereby, soon cease.  But
 if, after  an interval of  some  time,  the
 same symptoms are  renewed;  if the  pa-
 tient, having  been  well, becomes again
 feverish, and  restless, and that  without
 any new cause; if he complains of being
 languid and  uneasy, sleeps disturbedly,
 loses  his appetite, has a hot skin, a hard
quick pulse, and a flushed, heated coun-
tenance ; and neither irregularity of diet,
nor accidental cold, have been productive
of these ; mischief is most certainly  im-
pending, and  that most probably under
the skull.
  " .If.tne symptoms of pressure, such as
stupidity, loss of sense, voluntary motion,
&c appear some few days  after the head
has suffered injury from  external mis 
HEAD.                                  1?
chief, they do most probably  imply an
effusion of a fluid somewhere : this effu-
sion may be in the substance of the brain,
in its ventricles, between its membranes,
or on the surface of the dura mater; and
which of these is the real situation of such
extravasation, is a matter of great uncer-
tainty, none of them being  attended with
any peculiar  mark or  sign that can be
depended upon, as pointing it out precise-
ly; but the  inflammation   of  the  dura
mater, and the formation of matter be-
tween it and the skull, in consequence of
contusion, is  generally indicated and pre-
ceded by one which Mr. Pott  has hardly
ever known to fail; a puffy, circumscrib-
ed, indolent  tumour of the scalp, and a
spontaneous separation of the pericranium
from the skull under such tumour.
  " These appearances,  therefore, follow.
ing a smart blow on the head, and attend-
ed with languor, pain, restlessness, watch-
ing, quick pulse, head-ach, and  slight
irregular shiverings, do almost infallibly
indicate  an  inflamed dura mater,  and
pus, either forming or formed, between it
and the cranium."
  By detachment of the pericranium,  is
not meant every separation of it from the
bone which it should cover.  It may be,
and often is cut, torn, or scraped off,  with-
out  any  such consequence ;  but  these
separations are violent, whereas that which
Mr.  Pott  means  is spontaneous, and  is
produced by the destruction of those ves-
sels  by which it was connected with the
skull, and by which the communication
between it and the internal parts was car-
ried on; and therefore it is to be observed,
that it is  not the mere removal of that
membrane  which causes the bad symp-
toms, but it  is the inflammation of the
dura mater; of which inflammation, this
spontaneous secession of the pericranium
is an almost certain indication.
  Sometimes the scalp is so wounded at
the time of the accident, or so torn away,
as to leave the bone perfectly bare; and
yet the violence has not been such  as to
produce the evil just now spoken of.  In
this case, if the pericranium be only turn-
ed back, along with the detached portion
of scalp, there may be  probability of its
re-union ; and it should  therefore be im-
mediately  made clean  and replaced, for
the purpose of such experiment; which,
if it succeeds, will save time, and prevent
considerable  deformity.  Should the at-
tempt fail,  it can only be in consequence
of the detached part sloughing.  Hence,
removing it with a knife, though allowed
by  Pott, is now never practised.  Fre-
quently, when the scalp does not adhere
at once, it becomes attached to the cra-
nium afterwards by a granulating process.
     Vol. II.
When the detached piece sloughs, the
worst that can happen, is  an exfoliation
from the bare skull.
   Sometimes, the  force which detaches,
or removes the scalp, also  occasions the
mischief in question;  but, the integu-
ments being wounded  or  removed, we
cannot have the criterion of the tumour
o/the scalp for the direction of our judg-
ment.  Our whole attention must  be di-
rected to  the wound and  general  symp-
toms. The edges of the former will  digest
as well, and look as kindly, for a few tlays,
as if no  mischief  was  done underneatn.
But, after some little space  of time, when
the patient begins to be restless, and hot,
and to complain of pain in the head, these
edges will lose their vermilion hue, and
become pale and flabby.  Instead of mat-
ter, they will discharge a thin gleet, and
the  pericranium  will  loosen  from the
skull, to  some distance from the said
edges.  Immediately after  this, all the
general  symptoms are  increased and ex-
asperated ; and as the inflammation of
the membrane is heightened, or < xtended,
they become daily worse and worse, until
a quantity of matter  is formed, and col-
lected, and brings on  that fatal period,
which, though uncertain as to date, very
seldom fails to arrive.
   " Tlie  method of attempting the relief
of this kind of injury consists in two
points, viz. to endeavour to prevent the
inflammation of the dura mater; or, that
being neglected, or found impracticable,
to give  discharge to the fluid collected
within the cranium, in consequence of
such inflammation.
   " Oi all the remedies in the  power of
art,  for  inflammations of membranous
parts, there is none equal to phlebotomy.
To this truth many diseases bear testimo-
ny; pleurisies, ophthalmies, strangulated
hernias, &c. and if any  thing can particu-
larly contribute to the  prevention of the
ills likely to follow severe contusions of
the head,  it  is this  kind of evacuation;
but then it must be made tyse of in -such a
manneF as  to become truly a preventive;
that is, it must be made use of immedi-
ately, and freely."
   This eminent surgeon says, he is very
sensible that it will  in  general be found
very difficult to persuade a person, who
has had what may be called only a  knock
on the pate, to submit to such discipline,
especially  if he finds  himself  tolerably
well: yet, in many instances, the timely
use, or the neglect of this single remedy,
makes all  the difference between  safety
and fatality
   " It may be said, that as the force of^
the blow, the height of the fall, the weight
of the  instrument, &c. can  never pre-
    C 
18
HEAD
 cisely or cert.!inly determine the effect,
 nor inform us,  whether miscnief is done
 under the bone, or not, a large quantity
 of blood my be drawn off unnecessarily,
 in  order to prevent an  imaginary  evil.
 This is in sonic degree true; and if the
 advice just-given  was un versally follow-
 ed, many people  would be largely  bled
 without necessiiy ; but then, on the other
 hand, many a very valuable life would
 be preset ved, which, for want of this kind
 of assistance, is lost.   JWiil interest, prx-
 ndium an satis tutum sit, quod unicum est,
 is  an incontested maxim in  medicine;
 and if it be allowed to use such means as
 may be  in themselves hazardous, surely
 it cannot be wrong to employ one which
 is not so ; av least, if it be considered in a
 general sense, whatever it may accident-
 ally  pr ve  to some few  particular  indi-
 viduals."
   Acceleration, or hardness of pulse, rest-
 lessness, anxiety, and any degree of fever,
 after a smart blow on the head, are al-
 ways to be  suspec ed and attended to.
 Immediate, plentiful, and repeated evacua-
 tions by bleeding,  have, in many instances,
 removed these, in persons to whom, Mr.
 Pott verily  believes,  very terrible  mis-
 chief would have happened, had not such
 precaution been used.   In this, as well as
 some other parts  of practice, we nei'.her
 hava, nor  can have any other method of
 judging, than by comparing  together ca-
uses apparently similar. Mr Pott has more
 than once or twice seen that increased ve-
 locity and hardness of pulse, and that op-
 pressive languor,  which most  frequently
 precede mischief under  the bone, re-
 moved by  free and repeated blood-let-
 ting j and has often, much too often, seen
 cases end fatally,  whose beginnings  were
 full  as slight, but in  which  such  eva-
 cuation had been either neglected, or not
 complied with.  This  judicious  writer,
 " would by no means be thought to infer
 from hence, that  early bleeding will al-
 ways prove  a certain preservative;  and
 that they  only die, to whom it has not
 been applied : this, like all other human
 means, is  fallible;  and,  perhaps, there
 are  more cases   out of  its reach,  than
 within  it:  but, where  preventive means
 can take place, this is certainly the best,
 and the most frequency successful.
   "The second   intention, viz.  the  dis-
 cliarge of  matter,  collected  under the
 cranium, can be  answered  only by the
 perforation of it.
   " When, from  the symptoms and ap-
 pearances already described, there is just
 reason for supposing matter  to be formed
 under tlie skull, the  operation of perfor-
 ation cannot be  performed  too soon;  it
seldom  happens  that it  is  done  soon
enough.                      _
  " The propriety,  or impropriety, ot ap-
plying the trepl'ine, in cases where there
is "neither fissure, fracture, nor symptom
of extravasation,  is a point  which  has
been  much litigated,  and remains still
un-et led  either  by  writers   or  practi-
tioners.
  " When there is no reason  for suspect-
ing any of those injuries, either from the
symptoms, or from  the appearances ;  and
the pericranium,  whether the  scalp be
wounded or not, remains firmly attached
in all parts  to  the  skull; there certainly
is not (let the general symptoms be  what
they maj)  any  indication whereto apply
the instrument, and consequently no  suffi-
cient authority for using it  at all:  but
whenever that  membrane, after the  head
has received an external violence, sepa-
rates, or is detached  spontaneously  from
the bone underneath it, and such  separa-
tion is attended with the collection of a
small quantity of thin, brown ichor, an al-
teration of colour in the separated pericra-
nium,  and  an  unnatural dryness  of the
bone,  Mr.  Pott cannot  help thinking,
that there is as good reason  for  trepan-
ning, as in  the case of fracture;  he be-
lieves experience would vindicate  him,  if
he said, better reason ;  since  it is by no
means infrequent for  the former kind of
case to do well without such operation;
whereas suppuration under tlie skull ne-
ver can.
  " The  spontaneous  separation  of the
pericranium, if attended with  general dis-
order of the patient, with dullness, horri-
pilatio, languor, and some degree of fever,
appears to Mr. Pott, from all the observa-
tion he has  been capable of making,  to be
so sure and certain an indication  of mis-
chief underneath,   either in  present, or
impending,  that he should never  hesitate
about perforating  the  bone  in such cir-
cumstances.
  " When the skull has been once perfo-
rated, and  the dura  mater thereby laid
bare,, the state of the matter must prin-
cipally  determine  the  surgeon's future
conduct.   In some cases, one opening will
prove sufficient for  all necessary  pur-
poses;  in  others, several  may be neces-
sary.  This variation will depend on the
space of detached dura mater  and the
quantity of collected matter.  The repe-
tition of the operation is warranted,  both
by the nature of  the case,  and  by the
best authorities;  there  being po compa-
rison to be made between  the  possible
inconvenience  arising  from   largely de-
nuding the dura mater, and the certain,
as well as terrible evils which must follov 
HEAD
iy
 Oie formation and confinement of matter
 between it and the skull.
   " It  can hardly be  necessary to  ob-
 serve, that notwithstanding the operation
 of perf »ration be absolutely and unavoida-
 bly  necessary, vet the repetition of blood
 letting or  cooling laxative medicines,  the
 use of antiphlogistic remedies, and a most
 strict observance  of a low diet and regi-
 men, are as indispensably requisite  after
 such operation as before ; the perforation
 sets the membrane free from pressure, and
 gives  vent to  collected  matter,  but  no-
 thing  more;  the inflamed state of  the
 parts under the  skull,  and all the neces-
 sary consequences of such inflammation,
 call for all our  attention, full as much
 afterwards  as before; and although  the
 patient must have perished without  the
 use of the  trephine, yet, the merely hav-
 ing  used it, will not preserve him, with-
 out every other caution and care."
  Both tables of the skull sometimes ex-
 foliate in consequence of external violence.
 The dead bone must be removed,  as  soon
 as loose;  and,  if necessary,  the scalp
 divided for the purpose.

 3. Fissures  and Fractures of the Cranium,
           without Depression.

  " Fractures .of tlie cranium,  (says Mr.
 Pott) were,,by the ancient writers, divided
 into  many  different sorts, each of which
 was  distinguished by an appellation  of
 Greek etymology, borrowed either from
 the figure  of the  fracture, or the dispo-
 sition of the broken pieces.  These are to
 be found in most of the old books; but as
 they merely load the memory,  without
 informing the understanding, or assisting
 the  practitioner,   modern  authors have
 generally laid them aside.
  " This kind of  injury is divisible into
 two general heads, viz. those in which the
 broken parts keep their proper level,  or
 equality of surface, with the rest of the
 skull, and those in which they do not; or,
 in other words, fractures without depres-
 sion, and fractures with.
  " These  two distinctions are all which
 are really necessary to be made, and will
 be found to comprehend every violent di-
vision of the parts  of the skull (not made
by a cutting-instrument) from the finest
capillary fissure, up to the most  compli-
cated fracture:  for, fissures and fractures
differing from  each  other only  in  the
width of the breach, or in the distance  of
the separated parts, and the disposition of
broken  pieces,  in  large  fractures, being
subject  to  an almost  infinite varieiy, dis-
tinctions and appellations,  drawn  and
made from  these circumstances, might  be
 multiplied  to  even three times the old
 number without ;mparting the  smallest
 degree of useful knowledge  to  the man,
 whu snould be at the pa.ns to get them by
 heart.
   " What are the  symptoms  of a frac-
 tured cianium? is often asked; and there
 is hardly any one who does not,  from the
 authority of writers,  both ancient  and
 modern,  answer,  Vomiting,  giddiness,
 loss of sense, speech,  and voluntary  mo-
 tion, bleeding at  h'  ears, nose, and mouth,
 &c.  This  is  the  doctrine  of  Celsus,
 which has been most invariably copied by
 almost all succeeding authors, and impli-
 citly believed by almost all readers.
   " The  symptoms  just  mentioned  do
 indeed very frequently  accompany a brok-
 en skull, but they are not produced by the
 breach made in the  bone ; nor do they in-
 dicate such  breach  to have been  made.
 They proceed from  an affection of the
 brain, or from injury done to some of the
 parU within the cranium, independent of
 any  ill which the bones  composing it may
 have sustained.   They are  occasioned by-
 violence offered  to  the contents of the
 head in general;  are qui e independent of
 the  mere breach  made  in  the  bone;  and
 either do or do  not accompany fracture,
 as such fracture may happen to be, or not
 to be, complicated with such other ills.
   " They are frequently produced by ex-
 travasations of blood, or serum, upon, or
 between the membranes of the bi ain; or
 by shocks, or concussions of its subsU.nce,
 in cases where the skull is perfectly intire
 and unhurt.   On the other hand, the bones
 of the skull are sometimes cracked, brok-
 en, nay, even depressed, and  the patient
 suffers none of these symptoms.  In short,
 as the breach made  in the bone is not,
 nor can be the cause of such complaints,
 they ought not to be attributed to it; and
 that for reasons, which are by no means
 merely speculative.   For the practitioner,
 who supposes  that such symptoms do ne-
 cessarily and certainly imply  that  the
 cranium  is fractured, must regulate  his
 conduct by such supposition, and remove
 the scalp, very  often without  either  ne-
 cessity or benefit-, that  is, without disco-
 vering what  he  looks  for: and, on  the
 other hand, if he does  find the skull to
 be broken,  believing all these  complaints
 to be caused by, and deducible from  the
 fracture, he will most  probably  pa}  his
whole attention to that >upposeo < .use,
and  may think,  that when he has done
 what the rules of his  art prescribe  for
 such case, he has done all  that is in  his
power:----an opinion  not  unfrequently
embraced;  and which has  been  tlie de-
struction of many a  patient.  Per,  as on
one hand, the loss of sense, speech, and
voluntary motion, as well as the hemorr- 
20
nii ad.
hage from  the  nose, car.-, ke. are some-
times totally removed by,  or at least dis-
appear,  during  the use of free and" fre-
quent evacua ion,  without any  opera-
tion  on  the scalp or skull;  so,  on the
other,  as diese symptoms and appear-
ances are not produced by the solution of
continuity of the bone, they cannot be re-
medied by such chirurgie treatment as the
mere fracture may require.
  " If any  one  doubts the truth  of this
doctrine, (continues  Mr. Pott,) I would
desi' e him to consider the nature,  as well
as most  generally successful method of
treating  these  symptoms; and,  at the
same time, to reflect seriously  on the
operation of the trepan,  as practised in
simple,  undepressed fractures   of the
skull.
  "The  sickness, giddiness,  vomiting,
and loss of  sense and motion, can only be
the cmsequence  of an afli ction  of tlie
brain, as the common sensorium.   They
may  be produced by its having been vio-
lently shaken,  by a derangement of its
medullar} structure, or by unnatural pres-
sure made  by a fluid extravasated on its
surface, or within its ventricles;  but ne-
ver can be  caused by  the mere division
of the  bone, (considered  abstractedly) ;
which division, in a  simple fracture, can
neittier press on, nor derange, the struc-
ture of the  parts within the cranium.
  " If the solution of continuity in the
bnne be either produced by such a degree
of violence, as  hath caused a  consider-
able disturbance  in  the medullary  parts
of the brain, or has disturbed any of the
functions of the nerves going off' from it;
or has occasioned a breach  of any vessel,
or vessels whether sanguine or lymphatic,
and  that hath  been  followed  by an ex-
travasation, or lodgment of fluid; ihe
symptoms  necessarily  consequent  upon
such derangement, or such pressure, will
follow .-  but they do not follow, because
the bone is broken;  their causes  are su-
peradded to the fracture, and,  although
produced by 'he  s„me external violence,
are  yet perfectly  and  absolu ely  inde-
pendent of it: so  much so, that they are
frequently  found where no fracture is
  " The operation of the  trepan  is fre-
quently performed in the  case of simple
fractures, and that very judiciously and
properly; but  it  is not performed, be-
cause the bone  is  broken, or cracked: a
mere fracture, or fissure of the skull, can
never  require  perforation,  or that the
dura mater under it be  laid  bare; the
reason for doing this, springs from  other
causes than the fracture, and those  really
independent of it: they spring from tlie
nature of the  mischief which  the, parts
withir. tlie  cranium live sustained, and
not from the  accidental division of  the
bone.  From these  arise the threatening
symptoms;  from these all the hazard;
and from these,  the necessity, and vindi-
cation of performing the operation of  the
trepan.
  " If  a simple  fracture of the cranium
was unattended  in-present with any of
the  before-mentioned  symptoms,   and
there  was no reason  for  apprehending
any other evil in future, that  is,  if  the
solution of continuity in the bone was the
whole  disease, it c.uld not possibly in-
dicate  any  other curative intention, but,
the  general  one in all fractures,   viz.
union of the divided parts."
  In many cases of simple undepressed
fractures of the  cranium, it is true, that
trephining is necessary : but, .the reasons
for the opera) ion, in these instances,  are,
first,  the  immediate  relief of present
symptoms arising  from the pressure of
extravasated fluid; and, secondly,  the
discharge of matter, formed between the
skull  and dura mater, in consequence of
inflammation.   The operation  of   tre-
phining was also recommended by Pott,
as a preventive  of  ill  consequences;  a
practice, however,  which  is  now  never
adopted  by the  most eminent  surgeons;
and  many  writers  of  the  highest  repu-
tation,  especially  Desaultj Dease,   Mr.
John Bell, and Mr. Abernethy,  urgently,
and properly remonstrate against the  me-
thod.
  The latter remarks : " In the accounts,
which  we have  in the  former practice in
France, it is related, that surgeons made
numerous perforations  along  the  whole
track of a fracture  of  the cranium; and,
as far as I am able to judge, without  any
clear design.  Mr. Pott also advises such
an operation, with a view to prevent  the
inflammation and suppuration of the dura
mater, which  he so much  apprehended.
But, many  cases have occurred of late,
where, even in fractures with depression,
the patients have  done well without an
operation."
   Mr. Abernethy   next relates several
cases of fracture of the cranium with de-
pression,  which terminated  favourably,
although  no  operation was  performed.
Th s judicious surgeon thinks, that these
cases,  as well as a great many others on
record, prove,  that a slight  degree  of
pressure does not derange  the  functions
of the brain,  for a  limited time after its
application: and all those, whom  he had
an opportunity of knowing for any length
of time after  the accident, continued  as
well as if nothing of the  kind had  hap-
pened to them. In  Mr.  Hill's cases  in
surgery, two  instances of this sort are
related, and Mr. Hill  knew both  the pa- 
HEAD.                                  21
tients for many years afterwards;  yet, no
inconvenience arose.  Indeed, it  is  not
easy to conceive, that the pressure, which
caused no ill effects at a time, when the
contents of the cranium  filled its cavity
Completely, should afterwards prove in-
jurious,  when they have adapted'them-
selves to its altered size and shape.  Se-
vere illness, indeed, does often intervene
between  the receipt of  the injury, and
the time  of its recovery; and many sur-
geons might be inclined  to attribute this
to pressure ; but, it equally  occurs when
the depressed portion is elevated.  If  a
surgeon, prepossessed with the opinion,
that elevation of the bone  is necessary
in every instance of depressed cranium,
should have  acted  upon this  opinion in
several of the cases, which Mr. Abernethy
has related,  and afterwards  have  em-
ployed proper evacuations, his patients
would  probably hare had no  bad symp-
toms, and he would naturally  have attri-
buted their well-doing  to  the mode  of
treatment, which he had pursued: yet,
these cases did  equally  well without an
operation.  {Abernethy on Injuries of the
Head.)
  Depressed  fractures of the  skull not
being our immediate consideration,  we
need not expatiate upon them ;  but, it
seemed right to  make the preceding re-
marks, in order to shew how unnecessary
it must be to  trephine a patient, merely
because there is a fracture of the cranium,
and with a view of preventing  bad  conse-
quences.  Even when the fracture is  de-
pressed, it is not necessary,  unless there
are evident signs, that the degree of pres-
sure, thus produced on the brain,  is the
cause of existing bad symptoms.
  The inflammation and suppuration of
the parts,  beneath  the skull,  which Mr.
Pott wished so much to prevent by tre-
phining early, do not arise  from the oc-
currence of a breach in the cranium, but,
are the consequences of the  same vio-
lence, which was the occasion of the frac-
ture.  Hence, it is obvious, that removing
a portion of the bone  cannot in the least
prevent the inflammation and suppura-
tion, which must result from the external
violence  which was first applied  to  the
head;  but on the  contrary, such  a re-
moval being an additional violence, must
have a tendency to increase the inevitable
inflammatory mischief.
  From  what has  been  said,  it  is not
to be inferred,  however, that  trephin-
ing is  never proper,  when   there   is
a simple   undepressed fracture of the
skull.  Such injury may be joined with
an extravasation  of blood on the dura
mater ;  or, it may be followed by the for-
mation of matter between this membrane
 and the cranium ; in botli which circum-
 stances,  the operation  is essential to the
 preservation of the patient, immediately,
 but not before, the symptoms  indicative
 of the existence of dangerous pressure on
 the brain, begin to shew themselves.  (See
 Trephine.)
  A fracture  of the  skull, unattended
 with urgent symptoms, and not brought
 into the surgeon's view by any  accidental
 wound of the  integuments, often remains
 for ever undiscovered ; and as  no benefit
 could arise from laying it bare  by an in-
 cision, such practice  should  never be
 adopted.  The surgeon ought only to be
 officious  in this way, when he can ac-
 complish by it some better object,  than
 tlie merely satisfying his own  curiosity.
 And as we shall find from the perusal  of
 this article, and the one intitled, Trephine,
 that the removal of pressure off' the sur-
face of the brain is the only possible rea-
 son for ever perforating the  cranium  with
 this  instrument;  and  as  dividing the
 scalp is only a useful measure, when  it is
 preparatory to such  operation;  neither
the one,  nor the other, should ever be
practised, unless there exist unequivocal
symptoms, that there  is a dangerous de-
gree of pressure operating on  the brain,
 and  caused either by  matter, extrava-
 sated blood, or a depressed portion  of
 the skull.
  The true  mode  of preventing the bad
 effects, frequently  following, but not aris-
 ing from, simple fractures of  the skull,
 is not to  trephine,  but, to put in practice
 all  kinds of antiphlogistic means.  For
 this purpose, let the patient be repeatedly
and  copiously  bled, both from the  arm
 and temporal  arteries;  let  him be  pro-
perly purged;  give  him  antimonials;
 keep him on the lowest diet; let him re-
 main in the most quiet situation possible;
and if, notwithstanding  such  steps, the
symptoms  of inflammation  of  the  brain
continue  to>increase,  let his  head be
shaved and a large blister be applied t«
 it.  When, in spite of all these  measures,
 matter forms under the cranium, attended
 with symptoms of pressure, a  puffy tu-
 mour of  the injured part of the scalp, or
 those changes of the  wound, if there  is
 one, which  Mr. Pott has so excellently
 described, and we have  already related;
 not a moment should be  lost in delaying
 to perforate the bone with  the trephine,
 and giving vent to  the matter beneath.

 4. Fractures of the Cranium-nth Depression.

  " Simple  fractures of the  skull, or
those in  which the parts of the  broken
bone are  not depressed from their situa-
 tion (observes Mr. Pott) differ from what
 are called fissures, only in the distance of 
02
HEAD.
the edges of the breach from each other.
When tlie separation is considerable, it is
called a fracture ; when it i> very fine and
small, it is called a fissure.  The chirur-
gical  intention, and  requisite  treatment,
are the  same in each, v'u. to procure a
discharge for any fluid which may be  ex-
travasated in present, {here -we must under-
stand supposing tlie pressure of such extrava-
sation produces urgent symptoms) and to
guard against the formation, or confine-
ment of matter.  The prevention of sup-
puration  will, as  we  have  already  re-
marked,  be  best accomplished, not  by
perforating the cranium, as Mr.  Pott  ad-
vised, but by copious bleeding, evacua-
tions, blisters,  and a rigorous  antiphlo-
gistic regimen.  The confinement of mat-
ter, producing symptoms  of pressure on
the brain certainly indicates  the  immedi-
ate use of the trephine.
  " But, in fractures,  attended with  de-
pression, (says  Pott) the intentions  are
more.  In these  the  depressed parts  are
to be elevated, and such  as  are  so  sepa-
rated as to be incapable of reunion,  or of
being brought to lie  properly, and  with-
out pressing on the brain, are to be  to-
tally removed.  These circumstances  are
peculiar to a d pressed fracture; but, al-
though they are peculiar,  they must  not
be considered as sole, but, as additional
to those, which have been mentioned at
large under  the head of simple fracture :
commotion,  extravasation,  inflammation,
suppuration,  and  every ill, which can
attend on, or be found in the  latter,  are
to be met with in the former, and will re-
quire the same method of treatment."
That loose splintered pieces of the cra-
nium, when  quite detached, and already
in view, in consequence of the scalp  be-
ing wounded, ought to be taken  away, no
one will be inclined to question.   That
they ought also to be exposed by an inci-
sion, even when tlie scalp is unwounded,
and then taken  away,  whenever  they
cause symptoms of irritation, or pressure,
I  believe,  will be  universally  allowed.
But, the reader will  already understand,
from what has been said, in the preced-
ing section, that several  excellent sur-
geons do not coincide with Pott, hi believ-
ing, that every depressed  fracture of  the
skull necessarily demands the application
of the trephine.
   " There certainly are (says  Mr.  Aber-
nethy) degrees of this injury,  which it
would be highly imprudent to treat in
this manner.  Whenever  the patient  re-
tains his senses perfectlv, I should  think
it improper to trepliine him, unless symp-
toms arose, that indicated the nee- ssity of
it."  P.  21.
  Every  surgeoo, indeed, cannot be  too
fully impressed with the following truth,
tha; existing symptoms  of   dangerous
pressure on the brain, which symptoms
will be presently related, can  alone form
a true  reason for perforating the cranium.
The mode of operating, in  order to ele-
vate depressed  portions of the skuil,  is
explained in the article, Trephine.

5. Extravasationunder the Cranium ; Symp-
    toms of Pressure on the Brain, &c.

  Mr.  Pott  remarks, " the  shock,  which
the head sometimes receives by falls from
on  high, or by strokes  from  ponderous
bodies, does  not  infrequently  cause a
breach in some of the vessels, either of
the brain, or its meninges; and, thereby,
occasions extravasation of the fluid, which
should circulate through them.  This ex-
travasation  may be  the only  complaint
produced by the accident; or  it may be
joined  with, or added to,  a  fr cture of
the skull.  But this is not all, for it may
be produced not only when the cranium  is
unhurt by  the  blow, but even when no
violence of any kind has been offered to,
or received by the head."
  When  blood  is extravasated  beneath
the skull, the  violence which produces
the rupture of the vessel, usually stuns
the patient, from which state, provided
the quantity and pressure  of  the  blood,
and the force of the concussion be not too
great,  he gradually recovers, and regains
his  senses.   If  the first extravasation be
trival,  the  patient,  after  regaining his
senses, may only feel  a little drowsiness,
and go to bed.   The  bleeding from the
ruptured vessel continuing, and the pres-
sure on the  brain increasing, he becomes
more and more insensible,  and begins to
breathe in a slow, interrupted, stertorous
manner.  In cases of  compression, whe-
ther from blood or a depressed portion of
the skull, there is a general insensibility,
the eyes are half open, the pupil dilated,
and motionless even  when a candle  is
brought  near the eye; the  retina is in-
sensible; the limbs relaxed; the breath-
ing stertorous;  the pulse slow, and, ac-
cording to Mr. Abernethy, less subject to
intermission, than in cases of concussion.
Nor is the  patient ever sick, when the
pressure on the brain and the general in-
sensibility,  are  considerable;  for, the
very action of vomiting betrays an irrita-
bility  in the  stomach and  oesophagus.
These  symptoms are not peculiar to pres-
sure  from  blood,  but arise  also  from
that of many depressed fractures  cf the
skull,  and of suppuration under this part.
Th-y are all attributable to the unnatural
pressure made on the brain and  nerves,
and have too often been mistaken, as in- 
HEAD.
<?3
 ttcations of a disease, which, considered
 abstractly,  can never cause them; we
 allude to a simple undepressed fracture of
 the cranium, which may be accompanied
 by them, but cannot cause them.  They
 differ in degree, according to the quan-
 tity, kind, and situation of the pressing
 fluid. The hemorrhage from tlie nose and
 ears, which often follows violence applied
 to tlie  head,  leads to  no particular  or
 useful  inference :  we cannot even cal-
 culate,  by this sign, that the force has ex-
 ceeded a certain degree;  for, such bleed-
 ings take place, in many persons, from
 much slighter causes  than in others.
   The  preceding class of symptoms only
 inform us, that the  brain is suffering com-
 pression ; and, leaves us quite in  the dark,
 respecting several  other  very important
 circumstances.  " We not only have no
 certain  infallible rule,  whereby to dis-
 tinguish, what the pressing  fluid is,  or
 where it is situated, but we are, in many
 instances absolutely incapable of know-
 ing, whether the symptoms be occasioned
 by any  fluid at all;  for, a fragment  of
 bone, broken  off from the internal table
 of the  cranium,  and making an equal
 degree  of pressure, will produce exactly
 the same complaints." {Pott.) In detail-
 ing the  symptoms of pressure from blood,
 I  took  particular  notice  of the patient
 being at first generally stunned by the
 blow ;  of  his gradually regaining  his
 senses,  and of his afterwards relapsing
 into a state of insensibility again.   The
 interval  of  sense, which  thus occurs, i9
 a  circumstance, of the greatest conse-
 quence in making the  surgeon understand
 the nature of the case.
   " A  concussion,  and an extravasation
 (as Mr. Pott observes) are very  distinct
 causes of mischief, though not always very
 distinguishable.
  " M.  Le Dran, and others of tlie mo-
 dern French writers, have made a very
 sensible and  just  distinction  between
 that kind  and degree of loss  of sense
 which arises from  a mere commotion of
 the brain, and that which is caused by a
 mere extravasation, in those instances  in
 which the time of  the attack or appear-
 ance of such symptoms are different or
 distinct.  The loss of sense, which imme-
 diately follows the  violence,  say they,  is
 most probably owing to a commotion ; but
 that which comes on after an  interval  of
 time has past, is most probably caused by
 extravasation.
  " This distinction is certainly just and
 good, as far as it will go. That degree
 of abolition or diminution  of sense, which
immediately attends or follows  the blow
 or fall,  and goes  off again without the
 assistance  of art,  is in  all  probability
 occasioned, by the sudden shake or tem-
 porary  derangement of the contents of
 the  head; and the  same kind of symp-
 toms recurring  again  some  time after
 they had ceased, or not coming on until
 some time had passed from tlie receipt of
 the  violence, do most  probably proceed
 from the  breach of a vessel within  or
 upon the brain.  But unluckily, we have
 it not very often in our power to make
 this exact distinction.  An extravasation
 is often  made  so immediately, and  so
 largely,  at the  instant of the accident,
 that all sense and  motion are instanta-
 neously  lost, aud  never  again return.
 And it  also sometimes happens,  that
 although an extravasation  may possibly
 not have been made at the moment of the
 accident, and the first complaints may
 have been owing to commotion merely,
 yet a quantity of fluid  having been shed
 from its proper  vessels very soon after
 the  accident, and producing its  proper
 symptoms, before those caused by  the
 commotion have had time to go off, the
 similarity of  the effects of  each of these
 different causes  is such, as  to deprive us
 of all power of distinguishing between
 the one and the other, or of determining
 with any tolerable precision to which of
 them such symptoms as remain are really
 owing.
  "  When an extravasation of any kind is
 made, either upon  or  within the brain,
 if it be in such quantity, or so situated,
 as to disorder the economy of the ani-
 mal, it always produces such disorder,
 by making an unnatural pressure on  the
 parts where it lies.  The nature and  de-
 gree of the  symptoms  hereby produced
 are various and different in different per-
 sons, according to the kind, quantity, and
 situation  of  the pressing fluid.  Some-
 times it is mere fluid blood, sometimes
 blood in  a state  of coagulation,  some-
 times it  is a clear lymph,  and at  others
 blood and water are found mixed toge-
 ther; each of these is found either simple
 or mixed in  different situations, that is,
 between the  skull and  dura mater,  be-
 tween the  dura and  pia mater, or in  the
 natural  cavities  of the brain called  its
 ventricles,  and  sometimes,  in cases  of
 great violence,  they are  found at the
 same time in all these different parts.
 Sometimes a' considerable quantity  is
 shed instantly, at the time of tlie acci-
 dent ; and sometimes the breach by which
the effusion is made is so circumstanced,
 both as to nature and situation, that it is
 at first very small, and increases by faster
 or slower  degrees.  In tlie former, the
symptoms  are generally immediate and
 urgent,  and  the extravasation  is of the
 bloody kind ; in the latter,  they are fre- 
•:i
HEAD.
nuently slight at first, appear after some
tittle interval of time, increase gradually
till uiey become urgent or fatal, and are
in such case,  generally occasioned by ex-
travasated lymph.  So that although the
immediate appearance of bad symptoms
does most certainly  imply  mischief of
some kind or other,  yet, on the  other
hand, no man ought to suppose his pa-
tient free  from  hazard,  either because
such svmptoms do not shew themselves
at first,  or because  they appear to be
but slight: those which come on late, or
appearing slight at first, increase gradu-
ally , being full as much to be dreaded as
to consequence, as the more immediately
alarming ones; with  this material eliffer-,
ence between them, that the one may be
the consequence of a  mere concussion of
the brain, and may by means of quietude
and evacuation go quite  off;  whereas,
the other being most  frequently owing to
an extravasation of lymph, (though some-
times of blood also)'within the substance
•f the brain, are very seldom removed by
art."  {Pott.)
  The case of extravasation, between the
cranium and dura mater, is almost the
only one, which admits of relief from tre-
phining.   Mr.  Abernethy  informs us,
that, in the cases, which he has seen, of
blood extravasated, between the dura and
pia mater, on a division of the former
membrane being made for its discharge,
only the serous part of it could be eva-
cuated : for,  the coagulum  was spread
over the hemisphere of die brain, and had
descended, as low as possible, towards
its inferior part, so that very little relief
was obtained by  the  operation.  {P. 32.)
  Fractures of the cranium, which take
place across the  lower and front angle of
the parietal bone, and the rest of the track
of the  trunk, and large branches  of the
spinous artery of the dura mater, are
cases very apt to be attended with a co-
pious  extravasation.   This  vessel, and
others  more deeply seated, however, may
be ruptured, pour .^ut a considerable quan-
tity of blood, and induce urgent symptoms
of pressure  on the brain,  not only with-
out the co-existence of a fracture, but
even of any external  mark of violence on
the scalp.
  The effused blood  is,  more frequently,
situated below the part, on which the vio-
lence has operated, and, hence, when such
part is pointed out by a wound,  or dis-
colouration of the scalp, and the^jyuip-
toms of pressure are considerable, there
cannot be two opinions, respecting the
propriety of immediately trephm-ng, and
the place, where to m dee the perforation.
But, what is to be done, wi en dangerous
symptoms of pressure  prevail, without
any external mark to denote, what par*
of the head rece ved the blow, or whether
any at ail; for, a general concussion of
the head may produce an effusion ot blood
within the  cramum.  Under these  cir-
cumstances,  Mr.  Pott  was  against  the
operation, and says that " the only chance
of relief is from phlebotomy, and an open
belly; by wh.ch we may hope so to lessen
tlie quantity of the circulating fluids as to
assist nature in the dissipation or absorp-
tion of what has been extravasated.  This
is an effect which, although not highly
improbable in  itself, yet is no£ to be ex-
pected from a slight or trifling applica-
tion of the means  proposed.  The use of
them must be proportioned to the hazard
of the case.   Blood must  be drawn off
freely and repeatedly, and from different
veins; the  belly must be kept constantly
open, the body quiet, and the strictest re-
gularity of general regimen  must be ri-
gidly observed.   By these  means, very
alarming symptoms  have  now and then
been removed, and  people in seemingly-
very hazardous circumstances have been
recovered."
  If the symptoms, however were urgent,
it certainly might be proper to perforate
the cranium in the course of the spinous
artery of the dura mater.  If no blood
should be found under one parietal bone t
the operation might be done on the other.
This situation, we know, is the chief one
for copious extravasations  between the
cranium and dura mater, and if the blood
be more deeply effused, we have the con-
solation of knowing, that the patient had
the chance of that benefit, which might
have resulted  from the operation, had the
pressure originated from an extravasation
in one of the most common places, between
the dura mater and the .skull.
   This part of, practice, however, is ex-
ceedingly  doubtful  and obscure.  But,
should  the mode of  judging,  whether
blood lies  immediately under the .skull,
suggested by Mr. Abernethy, prove, inva-
riably correct, our line of,conduct may be
hereafter more easily detei mined, respect-
ing whether tlie  trephine should be ap-
plied in such dubious cases, or not. Even
when the injured  scalp shews where  the
violence has'operated,  the  criterion, we
are about to notice, may inform us, whe-
ther we should perforate the bone, or not;
for, though the extravasation is sometimes
found immediately  under  the  external
mark, yet, it often is not so; but, is in a
part distant from that mark, to which we
have nothing to  lead  us, and to  which,
indeed, if >ve knew it, we could not re ich.
 M   Abernethy his  observed, " tlia" un-
less one of the large arteries of  the dura
mater be wounded, the quantity of blood, 
HEAD.
25
 poured out, will probably be inconsider-
 able ; and  the  slight compression of the
 brain, which this occasions, may not be
 attended with any peculiar symptoms, or
 perhaps, it may occasion some stupor, or
 excite an  irritation,  disposing the subja-
 cent parts  to become inflamed.  It is  in-
 deed highly probable, that, in many cases,
 which have done well without an opera-
 tion,  such an extravasation has  existed.
 But,  if there be so much  blood on the
 dura mater, as  materially to derange the
 functions of the brain, the bone, to a cer-
 tain extent, will  no  longer receive blood
 from within, and by the operation, per-
 formed for its exposure, the pericranium
 must have been separated from its outside.
 I believe, that a bone, so circumstanced, will
 not be found to bleed"  In some cases, re-
 lated by this gentleman,  there was no he-
 morrhage ; twice he was able, by attend-
 ing to this circumstance, to tell how far
 the  detachment  of  the  dura mater ex-
 tended ; and often, when symptoms seem-
 ed to demand a perforation  of the skull,
 he has seen the operation contra-indi-
 cated by the hemorrhage from the bone,
 and as the event shewed, with accuracy.
 (P. 33.)
   Pott .justly remarks,  that " if the ex-
 travasation be  of blood, and that  blood
 be in a fluid state, small in quantity, and
 lying between the skull and dura mater,
 immediately under or near to the place
 perforated, it may happily be all discharg-
 ed by such perforation, and the patient's
 life may thereby be saved; of which many
 instances  are  producible.   But  if the
 event does not  prove so  fortunate, if the
 extravasation be so large or so  situated
 that the operation proved insufficient, yet
 the symptoms  having  been urgent, gene-
 ral evacuation  having been used ineffec-
 tually, and a wound or bruise of the scalp
 having pointed out the  part which  most
 probably  received the  blow: although
 the  removal of  that  part  of  the scalp
 should not detect any injury done to the
 bone, yet the symptoms still  subsisting, I
 cannot  help thinking, that perforation of
 the cranium is in these circumstances so
 fully warranted, that the omission  of it
 may truly be called a neglect of having
 done that which might have proved ser-
 viceable, and,  rebus sic stantibus, can do
 no harm.   It is very true,  that  no man
 can  beforehand tell  whether such opera-
 tion  will prove beneficial or not,  because
 he cannot  know the precise nature, de-
 gree, or situation of the mischief; but,
 this  uncertainty  properly  considered, is
 so far from being a dissuasive from the
 attempt, that it is really a strong incite-
 ment to make it; it  being fully as impos-
sible to know, that the extrav asated fluid
     Vol. II.
 does not lie  between the  skull and dura
 mater, and that  under the part stricken,
 as that it does; and if the latter  should
 be the case, and the operation be not per-
 formed, one, and most probably the only
 means of relief, will have been omitted.
   When there  is no interval of sense, be-
 tween the blow, and  the coming on  of
 perilous symptoms, it is frequently impos-
 sible to determine, whether  the mischief
 be owing  to the largeness and suddenness
 of the extravasation, to the violence of the
 shock, which the brain  has  received, or
 to both these causes at once, which, un-
 fortunately, is  too often the case.  In this
 latter  complication,  indeed, trephining
 will frequently be of no avail, even though
 it serve for the entire removal of all pres-
 sure off the brain; for, the patient cannot
 recover from the violence of the concus-
 sion, and never regains his senses.  This
 is no reason, however, why the chance of
 the operation doing good should  not  be
 taken,  when there are evident symptoms
*of pressure.    Let us in  these darkened
 cases, call to  mind  the sentiments  of
 Pott,  who says: " No man,  who is at all
 acquainted with this  subject, will ever
 venture to pronounce  or promise success
 from the  use of the trephine, even in the
 most  apparently slight cases; he knows
 that honestly he cannot; it is enough that
 it has  often been successful where  and
 when every other means have failed. The
 true and  just  consideration is this :  does
 the  operation of perforating the cranium
 in such case add at all to that degree of
 hazard which the patient is  in  before it
 is performed ? or can he in many instances
 do well without it.' If it does add to the
 patient's  hazard,  that is  certainly a very
 good reason  for laying it  aside, or for us-
 ing it very cautiously; but, if it does not,
 and the only objection made  to it,  is, that
 it frequently  foils  of being successful,
 surely it  cannot  be right to  disuse that,
 which has often been, not only salutary,
 but the causa sine qufi  non of preservation,
 merely, because  it is also  often unsuc-
 cessful, that is, because it is not infalli-
 ble."
   Mr. Pott thought, that, whenever the
 dura was detached from the inner surface
 of the skull by blood, as well as matter,
 the  pericranium  covering the outer part
 of the same bone would generally become
 detached also, and  this  spontaneous  se-
 paration of the latter  membrane he very
 justly regards, as a positive indication for
 the operation.  However, it  is very cer-
 tain, that if, in  cases of extravasation,
 the  surgeon were to  wait for this crite-
 rion, the operation would be done  too
 late, and, therefore, whenever unequivo-
 cal  symptoms  of pressure on the brain
     D 
26
HEAD.
 exist, trephining should never  be delay-
 ed.  Giving vent to the confined blood
 " may produce a cure, or it may prove
 only a temporary relief, according to the
 different circumstances of different cases.
 The disappearance, and even the allevia-
 tion of the most pressing symptoms is un-
 doubtedly a favourable circumstance,  but
 is not to be depended upon  as absolutely
 portending a good event.  Either a bloody,
 or limpid extravasation may be formed,
 or forming between the meninges, or upon,
 or within the brain, and may prove as cer-
 tainly pernicious in  future, as the more
 external effusion would have done, had it
 not been discharged; or  the dura mater
 may  have been  so damaged by the vio-
 lence of the blow as to inflame  and sup-
 purate, and thereby destroy the  patient."
 (Pott.)
   " If the disease (says the same eminent
 surgeon) lies between the dura and  pia
 mater, mere  perforation of the skull can
 do nothing; and, therefore,  if the symp-
 toms are pressing, there is no remedy but
 division of the outer of these membranes.
 The division of tlie dura mater is an ope-
 ration, which  I  have  several times seen
 done by others,  and  have often done my-
 self; I have seen it, and found it now and
 then successful; and, from those  instan-
 ces of success, am satisfied of the proprie-
 ty, and necessity of its being sometimes
done."  He next states, however, his sen-
timent, that wounding the dura  mater is
itself attended with dangerous consequen-
ces.   Mr. Abernethy's  opinion  of such
operation has already been given.
  " Upon the removal of a piece of bone
by means of the trephine; if the operation
has been performed over the part where
the disease is situated,  and  the  extrava-
sation be of the  fluid kind, anel  between
tlie cranium and dura mater; such fluid,
whether  it be blood,  water, or  both, is
immediately seen, and is partly discharg-
ed  by such opening ;  if,  on  the other
hand, the extravasation be of blood in a
coagulated >r grumous state, it is  either
loose, or in some degree adherent to the
dura mater; if the former of these be the
case, it is either totally or partially dis-
charged at t. e time of,  or soon after, the
operation, according to  the qwrntity  or
extent of the mischief;  if the latter, the
perforation discovers, but does not imme-
diately discharge it  In both instances,
the conduct of the surgeon,  with regard
to repetition of  the operation,  must  be
determined  by  the  particular  circum-
stances of each individual case ; a large
extravasation  must necessarily require a
more free removal of bone than a small
one; not only on account of freedom  of
discharge, but on  account of larger  de-
 tachment of dura mater j and a grumous
 or coagulated  extravasation  requires a
 still more free use of the instrument, not
 only because  the blood in such state is
 discharged with  difficulty, but because
 the whole surface of  the  dura  mater so
 cove; ed is always put  under the  necessity
 of  suppurating,  which  suppuration  has
 but one chance of a happy event, and that
 derivable from the free use of tlie perfor-
 ator.
   " When the extravasation is  not  be-
 tween the cranium and dura mater,  but
 either between the meninges, or  in  the
 ventricles of the brain, the appearances
 are not only different  from tlie preceding
 state of the case, but  from each other.
   " When the extravasated fluid lies be-
 tween the skull and dura mater ; as soon
 as that extravasation is discharged, or the
 grumous blood has been wiped off,  the
 dura mater appears  flaccid, easily yields
 to or does not resist  the impression of a
 finger,  and (the  discharge being made)
 enjoys that kind of motion, that  elevation
 and  depression, which  our fathers sup-
 posed it  to have naturally and always,
 but which is only the  consequence of  the
 circulation through the brain,  and  the
 artificial  removal of  the piece  of  bone.
 But when the extravasation is  situated
 between the meninges, or on tlie surface
 of the brain,  tlie appearance is not  the
 same.  In this case, there is no discharge
 upon removing the  bone;  and  the dura
 mater, instead of being flaccid and readily
 obeying the motion of the blood, appears
 full  and turgid, has little or no motion,
 and  pressing hard against  the  edges  of
 the perforation, rises into a kind of  sphe-
 roidal form in the hole of the perforated.
 bone.  If the extravasation be of the lim-
 pid kind, the membrane retains  its  natu-
 ral colour; but if it be either purely fluid
 blood, or blood coagulated and the sub-
ject  young, the colour of the membrane
 is so altered by what lies under it, that
 the nature of the case is always deter-
 minable from this circumstance.
  " Be  the extravasated  fluid  what  it
 may, it  has  no natural outlet; absorp-
 tion  was tlie only chance the patient had
 whereby to get rid of it without an opera-
 tion,  and that we must now suppose to
 have  failed; an artificial opening there-
 fore  must be made, by the division of the
 dura mater, and perhaps of the pia also.
 This  operation, under the circumstances
 and  appearances  already  mentioned,   is
 absolutely necessary,  and  has been sue.
 cessful;  it is performed to give discharge
 to what cannot be got rid of by any other
 means, and consists in a division of the
 membrane or  membranes, made in a cru-
 pial  form with a  point of a lancet.  The 
HEAD.
%x
  Operation in itself is extremely simple and
  e&s},  but Vhe  patient is thereby put  into
  the state  of one whose meninges have
  been wounded, with only this difference,
  that the wound made for this purpose is
  smooth and simple, and inflicted with the
  least  possible violence : whereas an acci-
  dental wound of the same pans may be
  lacerated, contused, and attended with
  circumstances  which must aggravate the
  evil, and may  induce worse  consequen-
  ces."  (Pm.)
    All cases of pressure on the  brain are
  attended with hazard of inflammation of
  this organ, and membranes.   This danger
  must  be averted as much as  possible, by
  the antiphlogistic  means,  recommended
  in speaking of fractures of the skull.

     CONCUSSION, OR  COMMOTION OP  THE
                  BHAIN.

    " Very  alarming symptoms, followed
  sometimes by the most fatal consequences,
  (Pott remarks,) are found to  attend great
  violence offered to  the head;  and, upon
Sthe strictest examination both of  the liv-
  ing and the dead, neither fissure, fracture,
  nor extravasation of any kind can be dis-
  covered.   The  same symptoms, and the
  same event,  are met with, when the head
  has received no injury at all ab externa,
  but has only been violently shaken ; nay,
  when  only the body, or general frame,
  has seemed to have sustained the whole
  violence."  And the  same writer after-
  wards accurately  observes, that  " the
  symptoms attending a concussion are gen-
  erally in proportion to the degree of  vio-
  lence, which the brain itself has  sustained,
  and which, indeed, is cognizable  only by
  tlie symptoms.  If  the concussion  be very
  great, all sense and power of motion are
  immediately abolished, and death follows
  soon : but, between this degree, and that
  slight confusion (or stunning, as it is call-
  ed) which attends  most violences, done
  to the head, there are many stages "  I
  think Mr. Abernethy has particularly ex-
  celled other writers, in his description of
  the symptoms  of concussion, which, he is
  of opinion, may be properly divided into
  three stages.
    " The frst is, that state of insensibility
  and derangement  of the bodily powers,
  which immediately succeeds  the accident.
  While it lasts,  tlie patient scarcely feels
  any injury that may be inflicted on him.
  His breathing is difficult, but in  general
  without stertor; his pulse  intermitting,
  and his extremities cold.   But  such a
  state  cannot last long; it goes off gradu-
  ally, and is. succeeded by another, which
  I consider as the second stage of concus-
  sion.  In  this,  the  pulse and respiration
become better, and, though not regularly
performed, are sufficient to maintain life,
and to diffuse warmth over the extreme
parts of the body.  The  feeling of the
patient is now so far restored, that he i9
sensible  if his skin be pinched;  but he
lies stupid, and inattentive to slight ex-
ternal impressions. As the effects of con-
cussion diminish, he  becomes capable of
replying to questions put to him in a loud
tone of voice, especially when they refer
to his chief suffering at the time,  as pain
in the head, &c.;  otherwise, he answers
incoherently, and  as if his attention was
occupied by something else.  As long as
the stupor remains,  the inflammation of
the brain seems to be moderate ; but as
the former abates, the latter seldom fails
to  increase;  and this constitutes the
third stage, which is the most important
of the series of effects proceeding from'
concussion.
  " These several stages  vary consider-
ably in their degree  and  duration; but
more or less of each will be found to take
place in  every instance where the  brain
has been violently  shaken. Whether they
bear any  certain proportion to each other
or not, I do not know. Indeed this will
depend upon  such a  variety of circum-
stances in the constitution,, the injury, and
the after-treatment, that it must be diffi-
cult to determine.
  " With regard to the treatment of con-
cussion, it would appear, that in the first
stage very little can be done; and per-
haps, what little is done, had better be
omi.ted, as the brain and nerves are pro-
bably insensible to  any stimulants that
can  be employed.  From  a loose, and, I
tlunk, fallacious analogy between the in-
sensibility  in  fainting,  and  that  which
occurs in concussion,  the  more powerful
stimulants,  such  as  wine,  brandy, and
volatile alkali, are commonly had recourse
to, as soon as the patient can be got to
swallow.  The same reasoning which led
to the employment of these remedies in
the first  stage, in  order to recall sensibi-
lity, has  given a kind of sanction to their
repetition in the  second, with a view to
continue and increase it.
  " But  here the  practice becomes  more;
pernicious, and less defensible. The cir-
cumstance of the brain having so  far re-
covered  its powers,  as to carry on the
animal functions in a degree  sufficient to
maintain lite, is surely a strong argument
that it will continue to do  sq, without the
aid of means which probably tend to  ex-
haust parts already weakened, by the vio*
lent ad 'ion they induce.
   " And it seems probable, that  these
stimula ing liquors  will  aggravate that
inflammation Which must  sooner or later 
 .»               I1EA

 ensue."  (Essay on Injuries of the Head,

   The following passage, extracted from
 a writer, who  has already been of mate-
 rial assistance to us in this subject, can-
 not be too deeply impressed on  the me-
 mory of every surgical practitioner .-
   " To  distinguish  between an  extrava-
 sation and a commotion, by the symptoms
 only, is frequently a very difficult matter,
 sometimes an impossible one.   The simi-
 larity of the effects in some cases, and tlie
 very small space of tune which may inter-
 vene between the going off of the one and
 accession of the .other, render this a very
 nice exercise of the judgment.  The first
 stunning or deprivation of sense, whether
 total or  partial, may be from either, and
 no man  can  tell from which; but when
 these first symptoms have been removed,
 or  have spontaneously disappeared ;  if
 such patient is again oppressed with drow-
 siness, or stupidity,  or  total or partial
 loss of sense, it then becomes most pro-
 bable, that the first complaints were from
 commotion, and that the latter are from
 extravasation;  and the greater the dis-
 tance of time between the two, the greater
 is the probability not only that an extra-
 vasation  is the  cause, but that the extra-
 vasation  is of the limpid kind, made gra-
 datim, and within the brain.
   " Whoever seriously reflects  on the
 nature of these two causes of evil within
 the cranium, and considers them as liable
 to frequent combination in tlie same sub-
ject, and at the same time considers, that
 m many instances  no degree of informa-
 tion can be obtained from the only person
 capable  of giving it (the  patient), will
 immediately be sensible, how very difficult
 a part a practitioner has to act in  many
 of these cases,  anel  how very  unjust  it
 must be  to call that ignorance ; which is
 only a just diffidence arising  from the
 obscurity of the subject, aiid the impossi-
 bility of attaining materials to form a clear
judgment.
  "When there is no reason to apprehend
 any  other injui), and  commotion seems
 to be the sole disease, plentiful evacuation
 by phlebotomy and lenient  cathartics, a
 dark room, the most  perfect quietude,
 and  a  very  low regimen,  are  the only
 means in our power ; and are sometimes
 successful."  (Pott)
  The reader, who wishes to acquire the
 most accurate information, concerning in-
juries of the head, may consult, with ad-
 vantage, various dissertations in theJUem.
 de I'Acad. de Chifnrgie; Traite' des Optra-
lions de Chirurgie par Le Dran,- Dease on
 h ounds of the Head; Pott on Injuries of
 tlie Head from  External  Violence;  Hill's
 Cases in Surgery; 0*Halloran on  the dif-
              HEM

 ferent Disorders arising from External In-
 juries of the Head; Some Cases in Desault's
 Parisian  Chirurgical Journal;  Jiltmoire
 sur les Plaies de T£te, in (Euvres Chirurgi-
 cale de Desault, par Bichat, Tom. 2; Las-
 sus, Pathologie Chirurgicale,  Tom. 2, p.
 252, &c. Edit. 1809.)
   HECTIC  FEVER.  See Fevers, Sur-
 gical.
   HEMERALOPIA. According to M.Du-
 jardin, this term  is derived from vtt*.i%ot,
 the day, *'*e>s, blind, and »^, the eye,
 and its right signification is therefore in-
 ferred to be diurna excitudo, or day-blind-
 ness.  (See Journal de Mtdecine, 'Tom. 19,
 p. 348.)  In the same  sense, Dr. Hillary
 (Obs.  on the Diseases of Barbadoes, p. 298,
 Edit.2,) Dr.Heberden (Med. Transactions,
 Vol. 1, Art. 5.) have employed the term.
   Hemeraiopia then, which is of very rare
 occurrence,  stands in  opposition to  the
 nyctalopia, of the ancients, or night-blind-
 tiess.  Moelern writers in general,  how-
 ever,  have used these terms in  the con-
 trary sense; considering the hemeraiopia,
 as  denoting sight during  the  day, and
 blindness in the night, and nyctalopia, as
 expressing night-seeing, owl-sight, as the
 French call it, and blindness during the
 day-time.
   Hemeraiopia, in the meaning of day-
 blindness,  is a very uncommon  affection.
 Dr. Hillary had never met with  but two
 examples.  He mentions a report,  how-
 ever, that there are a people in  Siam, in
 the East Indies, and also in Africa, who
 are subject to the disease of being  blind
 in the day time, and seeing well by night.
 (Mod. Univ. Hist.  Vol. 7.)
  Sauvages affirms, that the hemeraiopia,
 in his nomenclature called amblyopia cre-
 puscularis, had, about two years before,
 been  in  some degree  epidemic in the
 neighbourhood of  Montpellier, in the vil-
 lages,  in  damp situations adjoining the
 rivers, and that it particularly  affected
 the soldiers, who  slept in the open damp
 air.  They were cured, he says, by blis-
 tering, together with emetics and cathar-
 tics, and other evacuants.  (Nosol. Me-
 thod. Class 6, Gen. 3, Spec. 1.)
  See some ingenious observations on this
 subject in Dr. Rees's Cyclopaedia,  Art.
 Hemeraiopia.
  Scarpa, with the generality of modern
 writers, has considered the hemeraiopia,
 as an affection, in which the patient sees
 very well in the day, but, not in the night-
 time.
  The following observations are offered
by this celebrated Professor upon the dis-
ease, in the sense of night-blindness.
  " Hemeraiopia,  or  nocturnal blindness,
(says, Scarpa)  is properly nothing but a 
HEMERALOPIA-                               29
kind of imperfect  periodical  amaurosis,
most commonly sympathetic with the sto-
mach.  Its paroxysms come on towards
the evening, and disappear in the morn-
ing.  The disease  is endemic  in  some
countries, and epidemic, at certain sea-
sons of the year, in others.
  " At sunset, objects appear to persons
affected with the complaint, as if covered
with an ash-coloured veil,  which gradu-
ally changes into a dense cloud, which in-
tervenes between the eyes,  and surround-
ing objects.  Patients with hemeraiopia
bavejthe pupil, both in the day and night-
time7 more  dilated, and  less moveable,
than it usually is in healthy eyes.   The
majority of them, however, have the pupil
more or  less moveable in  the day-time,
and always  expanded and motionless at
night.  When brought into a room faintly
lighted  by a candle, where all the by-
standers can see tolerably well, they can-
not discern at all,  or  in  a very feeble
manner, scarcely any one object; or they
only find themselves able to distinguish
light from darkness ; and  at  moon-light
their sight is still  worse.  At day-break
they recover their sight, which continues
perfect, all  the  rest of the day, tdl sun-
set."
  This disease (according to Scarpa) may
commonly be completely cured, and often-
times in a very short time,  by treating it
on the same  plan by which the imperfect
amaurosis is remedied ; (see Amaurosis,-)
viz. by employing emetics, the resolvent
powders, and pills, and a  blister on the
nape of the  neck ;  and,  topically, the va-
pours of the caustic volatile alkali:  last-
ly, by prescribing, towards  the end of the
treatment, bark conjoined with valerian.
In cases, in which  the disease  has been
preceded by plethora, and suppressed per-
spiration, bleeding and sudorifics are also
indicated.
  In this manner, Scarpa  has  succeeded
in curing three subjects, affected with the
complaint.  The first was a boy, fourteen
years  old, who, for several weeks,  had,
in vain,  made use of the fumigation of a
sheep's liver, which had been fried.   The
second was a waterman ; the third a coun-
tryman, living  in  the rice-fields in the
vicinity of Pavia.  The two last were be-
tween thirty and forty years of  age, and
emaciated, with bloated,  sallow counte-
nances. After the boy had vomited a good
deal, in consequence of taking, at repeat-
ed  doses, in the space of two  hours, a
grain and a half of tartar emetic, dissolved
in four ounces of water, he took on the
following days,  the  resolvent  powders,
mentioned in Amaurosis.  They produced
nausea,  and two or three copious  stools,
ftgularly every  day.   On the evening of
the fifth day, the patient began to discern
surrounding objects by the faintest light
of a lantern.   Even since the emetic was
administered, he continued the topical use
of the vapours of the spirit of sal-ammo-
niac, and, on tlie sixteenth day, was per-
fectly cured. The waterman tiirice  vomit-
ed up a considerable quantity of a yellow-
ish, viscid matter.  Afterwards, he took
the resolvent powders, which made him
vomit  again on the third day, and, in the
day-time, he regularly exposed his eyes,
every  four hours, to the action  of the
ammoniacal vapours.  It was  not till the
eleventh  day, that he began to distinguish
objects in the night-time by a weak can-
dle-light.  The countryman vomited only
once copiously, but afterwards experien-
ced considerable nausea  during the nine
following days, on which he took  the re-
solvent powders, and he  daily discharged
by stool  a considerable quantity of green-
ish matter.  From  the  beginning, this
patient also employed the ammoniacal va-
pours, as  a topical application, and, on
the evening of the fourteenth day,  he be-
gan to see by candle-light.   From this
period, he continued to regain the  faculty
of seeing objects in the night-time regu-
larly  more and more, until he was com-
pletely cured. Towards the conclusion of
the treatment, Scarpa gave these patients
bark and valerian.
   But, the most expeditious cure was that
which Scarpa effected on Mauro Bonini,
a robust husbandman, of Donalasco, aged
two-and-twenty. This man began in March
to perceive, that, at sunset, he could only
distinguish objects very imperfectly. The
complaint increased  to  such  a  degree,
that,  in  the beginning of May, he was
almost totally blind in the evening.  On
the tenth of May, he came to the hospital
at Pavia.  Having examined both his eyes
in the day-light, Scarpa found both the
pupils very  much  dilated,  and  almost
motionless.  In the evening,  he repeated
the examination, and assured himself, that
the patient could not see objects, which
were visible to tlie  by-standers,  conse-
quently, that he was affected  with  hemer-
aiopia.   He also complained of bitterness
in his mouth,  heaviness in his head, and
his tongue was foul.
   On the eleventh, Scarpa ordered him an
emetic,  which did  not produce so much
effect  as was expected, and therefore a
stronger one was prescribed the next day.
It was composed of a dram and a  half of
ipecacuanha,  and   two grains of  tartar
emetic.  This dose made him vomit up a
considerable emantity of" yellow, greenish
matter.  The patient found his head re-
lieved immediately afterwards, and  the
bitterness in his mouth was no longer per- 
30
HEMERALOPIA.
  ceptible; the pupils of his ej es contracted
  a little, and became somewhat moveable
  in a vivid light. The ammoniacal vapours
  were now externally applied.   Tlie s* ne
  evening, tiie patient's sight seemed amend-
  ed,  and,  on  the thirteenth,  all internal
  medicines were discontinued, the vapours
  alone being used.
   On the fourteenth, the patient complain-
  ed again of bitterness in his mouth, and
  his  tongue appeared furred. Scarpa order-
  ed  him  to take the  resolvent powders
  every three hours.  These produced nau
  sea, and some evacuations from the bow-
  els.  The use  of the vapours  was con-
 tinued.  In the evening,  Scarpa exposed
 the patient to  the same degree of* light,
 as when the preceding examinations were
 made, and the patient was able to distin-
 guish all objects which were presented to
 him, exceedingly well.  On the sixteenth,
 the  symptoms of foulness in the stomach
 entirely  disappeared,  and the  pupil  of
 each eye contracted  in a moderate light,
 as in healthy persons.  The man left  the
 hospital,  on the seventeenth,  perfectly
 cured.
   Scarpa notices, that the ancients have
 strongly recommended, for the cure of this
 disease, the fumigations of a sheep's liver
 fried.  These were directed against the
 eyes through a funnel; and the liver, thus
 prepared,  was  also directed to  be eaten.
 Even in  Italy,  according t» Scarpa, this
 remedy in  general obtains confidenpe not
 only with  the vulgar, but also with sur-
 geons.  Some writers add, that  it is pro-
 ductive of wonderful success among the
 Chinese, who are said to  be very liable to
 this  complaint.   Scarpa  says,  he has no
 observations of his own to offer in support
 of this account;  but,  the case of the
 above-mentioned boy seems to be repug-
 nant  to it.  If,  however, the efficacy  of
 this  remedy should be a  matter of fact,
 surgeons will  possess another means  of
 curing noeturnal blindness, besides that
 which we have been explaining.
   Celsus, in the chapter on Mydriasis, has
 the  following words:  Quidam sine  ulld
 manifesto" causd subitd obexcati sunt.  Ex
 quibus nonnulli, cum aliquandiu nihil vidis-
 sent, repentind profusione alvi lumen recu-
perant.   Quo minus alienum videtur, et re-
 centi re,et interposito, tempore medicamentis
 quoquemolvn dejectiones, quxomnem noxiam
 materium per inferior a depellant.  This pas-
 sage, Scarpa thinks, refers not only to the
 J«at-meni of the dilated pupil, but also to
 that  ot the imperfect amaurosis, which
 occurs suddenly; and it  appears to him
 to merit the attention of practitioners.
   Ine first  part of what Celsus has stat-
 ed, viz. that persons who have been for
 some time affected with amaurosis, have
 regained their sight on being attacked by
 a diarrlicc^iHiJeems to Scarpa to t>e corro-
 borated by the case, related by  Doctor
 Pye. (Med. Obs. and Inq. Vol. 1.) A man,
 forty  years of age,  says  he,  had  been
 affected for two months with periodical
 amaurosis, which, for a certain time, had
 occurred regularly every evening,  but af-
 terwards came on irregularly, at different
 intervals,  with  considerable dilatation of
 the pupil,  and such  obscuration of sight
 on the approach of night,  that even the
 light of a candle could not be discerned.
 The man was  seized  with a diarrhoea.
 Doctor I'\ e ordered htm to lake, for eight
 successive  elays,  a potion  with  the kali
 praeparatum; then he prescribed an elec-
 tuary, composed of  bark,  nutmeg,  and
 sirup of orange-peek  The two latter in-
 gredients  were  added to  the  bark, on
 account of the continuance of the diarrhcea.
 The sec >nd day after the  electuary was
 taken, tlie  diarrhoea increased, and  the
 patient vomited copiously; after which he
 suddenly recovered his sight, so as to see
 equally well by day and by night  As the
 diarrhoea  continued,  the electuary  was
 omitted, after having been taken two days.
 A violent fever succeeded  the diarrhcea,
 and, it was remarked that,  during the
 highest stage of the  former,  the  patient
 became rather deaf,  but without losing
 his sight in  the night  or day-time.  Doctor
 Pye does not mention what  steps were
 taken to moderate the fever, which prov-
 ed fatal to the patient. At all events, adds
 Scarpa, it is a fact, that this spontaneous
 laxness of the bowels entirely freed the
 man from the imperfect periodical amau-
 rosis.  Scarpa entertains no doubt, that,
 by looking attentively into the numerous
 collection of medical observations,  one
 might  find  in them a  great many facts
 similar to the preceding one, shewing the
 influence of what he terms  morbific gas-
 tric stimuli over the organ of sight, and,
 consequently,  the great utility of a spon-
 taneous looseness of  the bowels  in  the
 cure of the imperfect amaurosis.
  But, says Scarpa, even if such exam-
 ples of the incomplete amaurosis  being
 dissipated in consequence of spontaneous
 vomiting, or copious evacuations from the
 bowels, produced entirely by nature, were
 rare, and noticed by few, we now have so
 many observations,  evincing the succes
 ful cure of this disease by means of such
 evacuations, artificially produced by eme-
 tics, and  internal resolvents,  that  no
doubt whatever  can be  entertained, con-
cerning the  accuracy  of the second part
of Celsus S  admonition, relative  to  the
present view of the imperfect amaurosis .-
 et  recenti  re,  interposito   tempore,  me-
dicamentis  quoque moliti dejectiones, gnx 
h Am                                  hem             si
ow7i<»i naritm materiam per infrriapa depel-  such as destrov the transparency of only
lant.  Of  this Scarpa remarks,  we  un-  a*certain portion of these parts.
doubtedly  have numerous,  satisfactory    The cure of this species of hemiopia
proofs, in the accurate  observations, re- ^.depends upon the' removal of the partial
lated by Schmucker and Richter; but our  opacity from which it originates.   (Sec
 confidence, says  Scarpa,  in the  above
 method of curing the imperfect and perio-
 dical amaurosis, must increase,  when we
 take notice,  that the most respectable
 practitioners of past times, have, in the
 majority of cases, cured this disease only
 by means of emetics, and internal resolv-
 ents, though, in their writings, they may
 have imputed  the success  of the treat-
 ment to other causes,  or the efficacy of
 other re medies, which they prescribed con-
 jointly  with emetics, and resolvents.
   Scarpa, after several valuable remarks
 on amaurosis in general, refers to the Mer-
 cure de France, for February, 1756, where
 there is an account of tlie cures performed
 by Fournier, on several subjects, affected
 with hemeraiopia.   The first were three
 soldiers, to whom an emetic was adminis-
 tered,  after bleeding   them.  The  next
 day, as they also complained of a heavi-
 ness in  their head, and nausea, the bleed-
 ing and emetic were repeated.  This ex-
 pedient removed all the above symptoms,
 and these three soldiers were no  longer
 unable  to see in the night-time.  Fouimier
 met with equal success, in treating eight
 Other soldiers upon  the same plan, .who
 were affected with the same disease, and
 belonged to the same garrison.
   Scarpa notices, that Pellier (Recueil de
 Mem. et Obs. sur I'CEil. Obs. 132.) cured
 Captain Micetti. of an hemeraiopia by re-
 peated  doses of tartar-emetic, a seton in
 the nape of the neck, and cooling, aperient
 beverages.  Pellier  also assures us, that
 he has several times  cured the recent im-
 perfect  amaurosis, by means of small doses
 of tartar-emetic,  and  topical  aromatic
 fumigations.  (Observ.  136—138.)  (See
 Scarpa  sulle Malattie degli Occhi. Venezia,
 1802)
   HEMIOPIA.   (from t)fucvf,  half, and
 uifz, the eye.)  A certain disorder of the
 eye, in  which the patient cannot see the
 whole of any object, which he is looking
 at, but only a part of it. Sometimes, he
 sees the middle, but not the circumfer-
 ence ; sometimes  the circumference, but
 not the centre;  while, on other occasions,
 it  is only the upper,  or lower half,  which
is  discerned.  Sometimes objects are seen
 thus  imperfectly,  whether distant, or
 near; sometimes, only when they are near,
 and not at a great distance.
   The causes of the hemiopia are divided
by Richter into four  kinds.
  To the first belong  opacities of tlie
rorn'%<  and  crystalline  lens, especially,
 Cataract, and Cornea, Opacities of.)
   Under  certain circumstances, persons,
 whose upper eyelid cannot Jae  properly
 raised, are affected with hemiopia.  They
 can only discern the k»\\ er half of an ob-
ject,  which is near and of large  size^ un-
 less they  go further from, it, draw their
 heads backward, or turn their eyes down-
 ward. The pupil, in particular instances,
 becomes drawn away from the mjddle of
 the iris.   This may also be a cause of he-
 miopia : it is a case, that does not admit
 of a  cure.  The affection may likewise
 proceed from a separation of the  iris from
 the margin of the cornea by external via-
 lence, on  other causes.  Here the cure is
 equally impracticable.
   The foregoing species of hemiopia  are
 merely effects of other diseases. Ttu fimrth
 and last kind is the  most important,  be-
 ing generally regarded as an independent
 disorder.   Sometimes,  it  appears rather
 to be the effect of a sudden and  transient
 irritation,  producing a morbid sensibility
 in the optic nerve.
   The causes of this sort of case,  if we
 can credit Richter, are mostly seated in
 the abdominal viscera.  When the  affec-
 tion is  more durable, forming what  has
 been termed amaurosis dmidiata, the same
 treatment is  indicated, as  in the  paralytic
 affections of the retina and optic nerve,
 in which  last disorders, indeed, it often
 terminates (See Richter's Anfangsgrunde
 der Wundarzn. Band. 3. Kap. 17.)
   HEMORRHAGE,  (from cufut,  blood,
 and pvyvvfii, to break out.)  Mamorrha-
gia, Bleeding.
   This is doubtless one of the most im-
portant subjects in Surgery.  The fear of
hemorrhage in fact retarded the improve-
ment  of our profession for ages; for the
ancients, ignorant how to stop bleeding,
were afraid to cut out the most trivial tu-
mour, or they did so with terror.   They
generally performed operations slowly ant]
imperfectly,  by means  of burning-irons,
or ligatures,  which the  moderns execute
quickly and  safely with a knife.  If tlie
old surgeons ventured to amputate a limb,
they only did so, when it had mortified, by
dividing the dead parts, and so great was
their apprehensions of bleeding, that they
only dared to cut parts which could no
longer bleed.  (John BeWs Principles  of
Surgery, Vol. 1. p. 142.)  But, not only as
a consequence of surgery, is hemorrhage
to be feared; it is also one of tlie most
alarming accidents, which  surgery is call- 
32
HEMORRHAGE.
ed upon to relieve. " Un sentiment naturel
attache a I'id/e de perdre son sang ; un ter-
rcur macliinale, dont I'enfant, qui commence
ti purler, et I'homme le plus dtcid6, stmt
igalement susceptibles. Onnepeutpoint dire,
que cette peur soit chimtrique.  Si I'on comp-
toil ceux, qui per dent la vie dans une bataille,
on verroit, que les trois Quarts out p4ri par
quelque hemorrhagic; et dans les grandes
operations de chirurgie cet accident est pres-
que toujours le plus formidable."  (Morand.
Mem. de  PAcad. Royale de Chirurgie, Vol.
5. &vo.  See Jones on Hemorrhage.)
  As the blood circulates  in the arteries
with much greater impetus and rapidity,
than in the veins, it necessarily follows,
that their wounds are generally  attended
with much more hemorrhage, than  those
of the latter vessels, and that such hemor-
rhage is more  difficult to suppress.  How-
ever, as the blood also flows through veins,
of great  magnitude, with great velocity,
bleedings from them  are frequently highly
dangerous, and sometimes unavoidably
fatal. When  an artery is  wounded, the
blood is  of a brght scarlet colour, and
gushes from the vessel per sal turn, in a very
rapid manner.  The blood issues from  a
vein in an even,  unbroken stream, and is
of a dark purple red colour.  It  is  of
great practical use  to remember,  these
distinguishing differences, between arte-
rial  and  venous hemorrhage,  because,
though the oozing  of blood may  be in
both cases equal in quantity, yet, in the
latter instance, one  is often justified in
bringing the sides of a wound  together,
without taking farther  means to suppress
the bleeding, while it would not be proper
to adopt  the same conduct, were there an
equ.d oozing of arterial blood.
   Dr. Jones has favoured  the world with
a matchless work, on the present subject;
and  as one gr. nd object of this Diction-
ary is to convey a careful  account  of all
the  latest  improvements in surgical sci-
ence, I shall first endeavour to  make the
reader acquainted with the more accurate
ideas, which  this gentleman  has  lately
pubhshed, relative to the doctrines of he-
morrhage. Afterwards, we shall consider
the surgical means to  be practised  in dif-
ferent cases.
   The sides of the arteries are divisible
into three coats.  The internal one is ex-
tremely thin,  and  smooth.   It is elastic,
and firm,  (considering its delicate struc-
ture) in the longitudinal direction, but so
weak in the circular as to be very easily torn
by the slightest force applied in that direction.
Its diseases shew, that it is vascular, and
it is also probably sensible.
   The middle coat is the thickest, and  is
composed of muscular fibres, all arranged
in a circular manner; they differ, how-
 ever, from common muscular fibres in be-
 ing more elastic,by which they alone keep
 a dead artery open, and of a  cylindrical
 form.  As this  middle coat has no longi-
 tudinal fibres, the circular fibres are held to-
 gether by a slender  connexion, which yields
 readily to any force, applied in the circum-
ference of  the artery.
   The external coat is remarkable for its
 whiteness, density, and  great elasticity.
 When an artery is surrounded with a tight
 ligature, its middle and internal coats are as
 completely  divided by it, as they could be by a,
 knife, while the external coat remains entire.
   Besides these proper coats,  all the ar-
 teries, in their natural situations, are con-
 nected, by  means of fine cellular sub-
 stance,  with surrounding, membranous
 sheaths. If an artery be divided, the divided
 parts, owing to their elasticity, recede from
 each other, and the length of the cellular sub-
 stance, connecting the artery with the sheath,,
 admits of in retracting a certain way within
 the sheath.
   Another important fact is : that when an
 artery is divided, its truncated extremities
 contract in c greater, or less, degree, and the
 contraction is generally, if not always,  per-
 manent.
   Arteries are furnished  with  arteries,
 veins, absorbents, and nerves ; a structure,
 which makes them susceptible of every change
 to which livir.g parts are subjected in common;
 enables them to inflame, wlien injured, and to
 pour out coagulating lymph  by which the in-
 jury is  repaired, or  t'e  tube permanently
 closed  (Si e Jones on Hemorrhage.)
    M.  Petit,  the surgt on, was the first,
 who, in 1731, endeavoured to explain the
 means, which nature employs for the  sup-
 pression of Hemorrhage.  He thought, that
 bleeding from a divided artery is  stopped
 by the  formation of a coagulum of blood,
 which is situated partly within, and partly
 without the vessel. The clot,he says, after-
 wards adheres to the inside of the artery,
 to its orifice, and to the surrounding parts;
 and, he adds,  that when  hemorrhage is
 stopped by a ligature, a coagulum is form-
 ed above  the ligature, which  only differs
 in shape,  from  the one, which takes place
 when no ligature  is employed.  His opi-
 nion leads him to recommend compression
 to support the coagulum.
    In 1736,  M. Morand published addi-
 tional interesting  remarks.  He allowed,
 that a coagulum had some effect in stop-
 ping hemorrhage ; but, contended, that a
  corrugation, or plaiting,  of the circular
  fibres of  the  artery which  diminish  its
  canal, and a shortening  and consequent
  thickening of its * longitudinal ones, which
  * Anatomists do not acknowledge that
such exist. 
Hemorrhage.
h?arly rendered it impervious, had some
Share in the process. He thought that the
Cavity of an artery might be obliterated,
by the puckering, or  corrugation, when
Circular pressure, as that of a ligature, is
made.  '
  Morand erred  chiefly in  explanation •
for, the contraction and retraction of divid-
ed arteries are indisputable facts, and, as
Dr. Jones remarks, this does not affect the
truth of his general conclusion,  tliat the
efiange, produced on a divided artery, contri-
butes with the coagulum  to stop tlie flow of
blood.
  Mr. Samuel Sharp (2d. Edit, of Opera-
tions of Surgery,1739,) supported the same
doctrine.  "The blood-vessels,  immedi-
ately upon  their  division,  bleed freely,
and continue bleeding, till they are either
stopped by art, or, at length contracting,
and  withdrawing  themselves, into  the
wound, their extremities are shut up by
coagulated blood."
  Pouteau (Mtlanges de Chirurgie, 1760,)
denied, that a coagulum is always found
after an artery is divided; and,  when it
is, he  thought it only a feeble and subsi-
diary means  towards the suppression of
hemorrhage.   He contended, that the re-
traction of the artery  had not been  de.
monstrated, and could not be more effec-
tual, than  a coagulum.  His theory was,
that  the swelling of tlie cellular mem-
brane, at the circumference of the cut ex-
tremity of the artery, forms the principal
impediment to the flow of blood; and that
a ligature is useful in promoting a more
immediate and extensive induration of the
cellular substance.
  Gooch, White, Aikin, and Kirkland, all
oppose Pelit's doctrine of coagulum.  The
first  blends some of Pouteau's theory with
his own, by observing, that" when p small
artery is totally divided,  its retraction
may  bring it under the surrounding parts,
and  with the natural  contraction of the
diameter of  its mouth,  assisted by  the
compressive  power  of those parts,  in-
creased by their growing tiimid, the ef-
flux  of blood may be stopped.'*
  White was convinced, from what Govich
had  suggested, and  Kirkland confirmed,
that the arteries, by their natural contrac-
tion, coalesce, as  far as their first ramifi-
cation.
  Dr. Jones admits, that an artery con-
tracts  after it has been divided;  and his
experiments  authorize him  to say,  that
the contraction of an  artery is an impor-
tant  means, but, certainly not the only,
nor  even the  chief means, by which he-
morrhage  is  stopped.    The  impetuous
Mowing of the  blood through  the wound
of the artery would resist the contraction
     \oi..ll.
of the vessel in such a degree, that would*
in almost every instance, be attended with
fatal  consequences,  when  the  artery is
above a certain size, were it not for the
formation of a coagulum.   (Jones.)
  Mr. J. Bell thinks, that  when  hemor-
rhage stops of its own accord,  it is  nei-
ther from the  retraction of an artery, nor
the constriction of its fibres, nor the form-
ation of clots, but, by the  cellular sub*
stance, Which surrounds the artery, being
injected with bloocL
  We must refer the reader to Dr. Jones'
Work for a complete exposure of the in-
consistencies and absurdities in Mr. Bell's
account of his own theory.  (See P. 25,
&fc.)
  Dr. Jones very accurately concludes his
criticisms  on  Mr. Bell with observing,
that  if this gentleman really  means to
confine his doctrine of the natural means
of suppressing hemorrhage  to the injec-
tion of the cellular substance, round the
artery, with blood, he dwells improperly
on one of the  attendant circumstances to
the exclusion  of the  retraction,  and con-
traction of an artery,  and the formation
of a distinct clot, all primary parts of the
process.
  The blood,  besides  filling the cellular
substance round the artery,  also fills the
Cellular substance at the mtuth of the ar-
tery in  a particular  manner; for, the di-
vided vessel, by its retraction within its
cellular sheath, leaves a space of a deter-
minate form, which, when all tlie circum-
stances necessary for tlie suppression of
hemorrhage operate, is gradually filled up
by a distinct clot. (Jones.)

MEAHS OF NATCRE IN STOPPIXO  BLEEDINO
         FROM  DIVIDED ARTEniES.

  Dr. Jones has given  a faithful and ac-
curate detail of a series of experiments on
animals, which demonstrate  " that the
blood, the action, and even the structure
of the arteries, their sheath,  and the cel-
lular substance connecting them  with it,'*
are concerned  in stopping bleeding from a
divided artery of moderate size, in t|ie fol-
lowing  manner: " An  impetuous flow of
blood, a sudden and forcible retraction of
tlie artery within its sheath, and a slight
Contraction of its extremity, are the imme-
diate, and almost simultaneous, effects of
its  division.   The natural impulse, how-
ever,  with v hidi the blood  is driven on,
in some measure counteracts the retrac-
tion,  and resists the  contraction of the
artefy.  The blood is effused into the cel-
lular  substance, between the artery and
its sheath, and passing through that canal
of the sheath,  which had been formed bv 
HEMORRHAGE.
the retraction of the artery,  flows  freely
externally, or is extravasated into the sur-
rounding cellular membrane, in propor-
tion to the open, or confined state of the
wound.  The retracting artery leaves the
internal surface of the  sheath  uneven,
by  lacerating,  or stretching the cellular
fibres, that connected them.  These fibres
entangle the blood, as it  flows,  and thus
the foundation is laid for the formation of
a coagulum at the mouth of the artery,
and which appears to be completed  by
the blood, as it passes through this canal
of the sheath, gradually adhering and co-
agulating, around its internal surface, till
it completely fills it up from the circum-
ference to the centre."   (Jones, p. 53.)
  The effusion of blood into the surround-
ing cellular membrane, and  between the
artery and its sheath; but, in particular,
the diminished  force of the circulation
from loss of blood, and a speedy coagu-
lation of  this  fluid in this circumstance,
most   essentially  contribute, says  Dr.
Jones,  to the desirable effect.
  It appears then, that a coagulum, which
Dr. Jones calls the external one, at the
mouth of the artery, and within its sheath,
forms the first  complete obstacle to the
continuance of bleeding, and  though  it
seems  externally like  a continuation of
tlie artery, yek on slitting open this ves-
sel, its termination  can be plainly ob-
served, with the coagulum shutting  up
its  mouth, and contained in its sheath.
(Jones, p. 55.)
  No collateral  branch being very near
the impervious mouth of the artery, the
blood just within it is at rest, and usually
forms a slender conical coagulum,  which
neither fills up the canal of the artery,
nor adheres to its sides, except by a small
portion of the circumference of its base,
near the extremity of the vessel.  This
coagulum is distinct from the former, and
what Dr. Jones calls the internal one.
   The cut end of the  artery next  in-
flames, and tlie vasa vasorum pour out
lymph, which fills up  the extremity  of
the artery, is situated between  the inter-
nal and  external  coagula,  is somewhat
intermingled with  them, or adheres to
them,  and is firmly united  all round to
the internal coat of the vessel.   Dr. Jones
further states, that the  permanent sup-
pression of the hemorrhage chiefly  de-
pends  on this coagulum of lymph; but,
that tlie end of tlie artery is also secured
by a gradual contraction, which it  under-
goes, and by an effusion of lymph between
its tunics, and into the surrounding cellu-
lar substance;  whereby  these  parts be-
come thickened, and so incorporated with
each other, that one cannot  be discerned
from the other.  Should the wound in the
integuments  not heal  by the first inten-
tion, the coagulating lymph, soon effused,
attaches the artery firmly to the subjacent
and lateral parts, gives it a new covering,
and entirely excludes it from the outward
wound.  (Jones, p. 55.)
  The same  circumstances are  also re-
markable in  the portion of  the vessel,
most remote from the  heart.  Its  orifice,
however, is usually more contracted, and
its  external  coagulum smaller, than  the
one, which attaches itself to the other cut
end of the artery.  (Jones on Hemorrhage,
p. 56.)
  The impervious extremity of the arte-
ry, no longer allowing blood to circulate
through it,  the portion, which lies be-
tween it and the first lateral branch gra-
dually contracts, till  its cavity is com-
pletely obliterated, and its tunics assume
a ligamentous appearance.   The external
coagulum, which, in the  first instance,
had stopped  the hemorrhage, is absorbed
in a few days, and the coagulating lymph,
effused around it, and by which the parts
were thickenefl, is gradually removed, so
that they resume again their cellular tex-
ture.  (Jones, p. 57.)
   At a still later period, the ligamentous
portion is reduced to a filamentous state,
so that the artery is, as it were, completely
annihilated from its  cut end to the first
lateral branch.  Long, however,  ere this
final change is accomplished, the  inoscu-
lating branches have become considerably
enlarged, so as to establish a free commu-
nication, between the  disunited  parts of
the main artery.  (Jones, p. 58.)
   When an artery has been divided at some
distance from a lateral branch, three coagula
are formed : one of blood externally, which
shuts up its  mouth; one of lymph, just
within  the extremity of its  canal;  and
one of blood, within its cavity, and conti-
guous to that of lymph.  But, when the
artery  has  been divided near a  lateral
branch,  no internal coagulum of  blood  is
formed.  (Jones, p. 63.)
   The external coagulum is always form-
ed, when the divided artery is  left to na-
ture ; not so, however, if art interferes, for
under the application of the  ligature  it
can never form.  If agaric,  lycoperdon,
or sponge, be used, its formation is doubt-
ful, depending entirely upon the degree of
pressure, that is used; but, the internal
coagulum of blood will be equally formed,
whether the  treatment be left to ait, or
nature, if no collateral branch is near the
truncated  extremity of the artery;  and
lastly, effused lymph, which, when in suf-
ficient quantity, forms a distinct coagu.
lum, just at the mouth of the artery, will 
HEMORRHAGE.
3*
be always found, if tlie hemorrhage is per-
manently suppressed.  (Jones, p. 74.)

hkans,  Which  hature  employs  fob
  suppressing  tue  hemorrhage  from
  pcwctcred  or   partialli   divided
  arteries.

  The suppression of hemorrhage by the
natural means is much more easily accom-
plished, when an artery is completely di-
vided, than when merely punctured,  or
partially divided. Completely dividing a
wounded artery was one means practised
by the ancients in order to stop hemor-
rhage: the  modems  frequently do the
same thing, when bleeding from  the tem-
poral  artery proves troublesome.
  Dr. Jones has  related  many experi-
ments, highly  worthy  of perusal, and
which were undertaken to investigate the
present part of the subject of hemorrhage.
This gentleman, however, owns, that, in
regard to the temporary means by which
bleeding from a punctured artery is stop-
ped, he has but little to add to what Petit
has explained, in his third publication  on
hemorrhage.   (Mem.  de I'Acad.  des Sci-
ences; 1735.)   The blood is effused into
tlie cellular substance,  between the  ar-
tery  and its sheath,  for some distance,
both  above and below the wounded part;
and when the parts  are examined, a short
time after the hemorrhage has completely
stopped, we find a stratum of coagulated
blood between the artery and its sheath, ex-
tending fromafewincb.es belowthe wound-
ed part to two, or three inches above it, and
somewhat thicker,  or more  prominent
over  the wounded part, than elsewhere.
   Hence, rather than say the hemorrhage
 is stopped by a coagulum, it is more  cor-
rect to say, that it is stopped by a thick
lamina of coagulated blood, which, though
somewhat thicker at the wounded part, is
perfectly continuous with the coagulated
blood lying between the artery and its
 sheath.   (Joiws, p. 113.)
   When  an artery is punctured, the he-
 morrhage, immediately following, by  fill-
 ing up the space, between the artery and
 its sheath, with blood, and consequently,
distending the sheath, alters the relative
 situation of the puncture in the sheath to
 that  in the artery, so that they are  not
 exactly  opposite to each other; and by
 that  means a layer of blood is confined by
 the sheath over the puncture in the artery,
 and,  by  coagulating there, prevents  any
 further effusion of blood.
   But,  this coagulated blood, like the
 external coagulum of a divided artery,
 affords  only a temporary barrier to the
 hemorrhage: its permanent  suppression
is effected by a process of reparation, or
of obliteration.
  Dr. Jones's experiments shew, that an
artery, if wounded only to a moderate
extent, is capable of reuniting and heal-
ing so completely, that, after a certain
time, the cicatrization cannot be disco-
vered, either  on its internal, or extefnal
surface;  and that even oblique and trans-
verse wounds  (which gape  most) when
they do not open tlie artery to a greater
extent, than one-fourth  of its circumfer-
ence, are also filled  up and healed by
an  effusion  of coagulating  lymph from
their inflamed lips, so as to  occasion but
little, or no obstruction to the canal of
the artery.  The utmost magnitude of &
wound, which will still allow the  conti-
nuity of the canal to be preserved, is difc
ficult to  be learnt;  for, when the wound
is large, but yet capable of being  united,
such a quantity of coagulating lymph  is
poured out, that the canal of the vessel,
at the wounded part,.is more or less filled
up  by it. And when tlie wound is still
larger, the vessel becomes either torn or
ulcerated completely across, soon after-
wards, by which its complete division^
accomplished.
  The lymph, which  fills up the wound
of an  artery,  is poured out very freely
both from the vessel and the surrounding
parts, and it accumulates around the  ar-
tery, particularly, over the wound, where
it forms a more distinct tumour.  The
exposed surrounding parts at the same
time inflame, and pour out coagulating
lymph, with which  the whole surface  of
the wound becomes covered, and which
completely excludes  the artery from the
external wound.  This lymph granulates,
and tlie wound is filled up and healed  in
tlie usual manner.   (See Jones on Hemorr-
hage, p.  113, &c.)

 SURGICAL MEAKS OF  SUPPRESSING HEMOR-
                 RHAGE.
                                     •
   It must be plain to every one, who  un-
derstands the  course of the circulation,
 that pressure, made on that portion of a
 wounded artery, which adjoins the wound
 towards the heart, must check the effusion
 of blood.  The current of blood in  the
 veins, running in  the opposite direction,
 requires the pressure to be applied to
 that side of the wound, which is most
 remote  from the  heart.  As  pressure is
 the  most rational  means  of impeding
 hemorrhage,  so it  is the most effectual;
 and almost all the  plans,  employed  for
 this purpose, are only modifications of it.
 The tourniquet, tlie  ligature, the applica-
 tion of a roller  and compresses,  even 
36                            HEMORRHAGE.
  agaric itself, only become useful in the
  suppression of hemorrhage, on the prin-
  ciple of pressure, the cautery,  caustics,
  and styptics excepted.

    MEANS EMPLOYED RT THE ANCIE-XTS.

    In order to prevent a wounded person
  from  dying of  hemorrhage, Celsus ad-
  vises the wound to be filled with dry lint,
  over which is to be laid a sponge dipped
  in cold water,  and pressed oh  the part
  with the hand.   If, notwithstanding this,
  the hemorrhage should continue, he re-
  commends repeatedly applying fresh lint,
  wet with vinegar; but, he  is against the
  use of corroding escharotic applications,
  on account of the inflammation, which they
  produce; or only sanctions the  employ-
  ment  of the mildest ones.  When  the
  hemorrhage resists these  methods, he ad-
  iiises two ligatures to be applied to the wound-
 ed part nf the vessel, and then to divide the
 portion .i mated between them:—"  Quod si
 ilia quoque proftuvio vincunter, vend, qux
 sanguinemfundunt. apprehendendx  circaque
 itl, quod ictum est, duobus  locis deligandx,
 intercidendeque sunt, ut et in seipsx co'e'ant,
 el nihilominus oru prxclusa  habeant."  Lib.
 5. cap. 26.  When the ligature is  imprac-
 ticable, he proposes the actual cautery, if
 the wound should bleed sufficiently, and
 there should be no nerves, nor muscles at
 the bleeding part.
   Galen also mentions tying  the vessels
 to  stop the hemorrhage  from wounds;
 and there  are some traces of the same
 information in other authors, who lived
 before him,  as  Archigenes, and  Rufus.
 However, it is more  than  probable, that,
 in their days, the ligature was little used,
 as we must infer from  the  multitude of
 topical  astringents,  caustics, and other
 applications, which  they have  advised
 for stopping bleeding, and in which they
 Would have put lrs3 confidence, had they
 been familiarly acquainted with  the m>e
 of the ligature.   No one can doubt,  that
 they would very soon have  tied the  ves-
 sels after amputations,  had thev  had
 many opportunities of seeing  the  advan-
 tage, of the ligature; but,  so far  were
 they from adopting such practice, that,
 Albucasis, a long while  afterwards, re-
 tused to amputate a wrist, lest he should
 see Ins patient bleed to death.
  Pare passes for Hie first, who employ.
 ed  %he  ligature  after amputation.  H-s
 method having  been  attacked,  he  mo-
 desty defends it in the part of his works
intitled, Apohgie.  He takes gre.t care to
 impute  the ongin of it to  the ancients,
 and cites many of them, who have made
 inent10n  of it.   However, he thinks its
 utility  m  amputations of  such high con-
 sequence, that he considers  himself an
 inspired by  the  Deity  in having first
 adopted this practice.
   The  method, in  which  the ancients
 placed most confidence, for stopping he-
 morrhage after the  amputation of a limb,
 was  the cauterization  of the  cut  vessel,
 and part of the surrounding flesh.  The
 parts, thus  affected by the  heat, formed
 an eschar,  of greater, or less thickness,
 which blocked up the opening of the ves-
 sel, and lundered  the blood from escap-
 ing.   The separation of the eschar, how-
 ever, which frequently  took  place  too
 soon, occasioned a return of the hemor-
 rhage, and  rendered it the  more dange-
 rous, as its suppression  became  more
 difficult, than before the cautery was  ap-
 plied.  The instrument being  too much,
 heated,  even,  sometimes,  immediately
 brought away  with it the eschar,  which
 it had just formed.   At the present time,
 the cautery is never employed, as a means
 of suppressing hemorrhage,  or, at most,
 only in a few very unusual cases, in which
 neither compression, nor the  ligature can
 be made use  of.   In Great Britain, the
 cautery  may be said to be entirely ex-
 ploded ; but, in France, the best hospital
 surgeons now and then employ it to stop
 bleedings  from the antrum, and the
 mouth.
   It was once a practice, to apply pledgets,
 dipped in boiled turpentine, to the mouths
 of the bleeding vessels : of this it is only
 necessary to say, that the method now has,
 long been mpst justly abandoned.


      ASTRINGENTS, STTPTICS,  &C.

   he Dran, in his  treatise on  the opera-
 tions  of surgery, says, that  a  button of
 vitriol, or alum, applied  and  properly
 confined on the extremity of the vessel, is
 sufficient to stop the hemorrhage in am-
 putations.  Heister  recommends the ap-
 plication of  vitriol, in preference to the
 ligature, in  the amputation of the  fore-
 arm.   Great praises have also been con-
 terred on agaric, and sponge, for  their
 styptic properties.  Solutions of iron, and
 all the mineral acids in various forms,
 have been recommended to the publick
 as remedies  of the  same kind, and pus.
 sessing great efficacy.  The ancients,  in-
 deed, had already exhausted this class of
 remedies in such a  degree, that the pre-
 tended  discoveries  of  the moderns,  in
 t»s way, may almost all be met with in
 thnr  writings;  and  the  little success,
 attending their practice, especially, when
 bleeding from a considerable artery was
 to be  suppressed,  clearly  shews what
little reliance we ought to place on means,' 
HEMORRHAGE.
37
of this  description.   (Encyclopedic M6-
thodique; Partie Chirurgicale.) Styptics do,
indeed,  possess  the  power  of stopping
some  hemorrhages from small arteries;
but, they ought never to be trusted, when
large ones are concerned.
  There is no doubt, that cold air has a
styptic property; by which expression 1
mean, it promotes the contraction of the
vessels,  for,  no styptics can contribute to
make  the  blood  coagulate, though  such
an erroneous idea is not uncommon.  We
frequently tie, on the surface of a wound,
every artery, that betrays the least dispo-
sition  to bleed,  as long as the  wound
continues exposed to the air.   We bring
the opposite sides of this  wound into
contact, and put the patient to bed.  Not
an hour elapses, before  the renewal of
hemorrhage  necessitates us to remove the
dressings.  The  wound  is again  exposed
to the air, and again  the bleeding ceases.
This often happens in the scrotum,  after
the removal  of a testicle, and on the chest,
after the removal of a breast. The proper
conduct, in such cases, is not to open the
wound unnecessarily, but, to  apply wet
linen to the  part so as to produce such an
evaporation from, its surface, as shall cre-
ate a sufficient degree of cold to stop the
bleeding.  As all styptics irritate,  judi?
cious  practitioners seldom apply them to
recent wounds. It is sometimes, however,
very proper to employ them tp suppress he-
morrhages from  many diseased surfaces,
where the vessels seem to have lost their
natural disposition to contract.

             COMPRESSION.

  We have   already remarked,  that  all
tlie best means of checking hemorrhage,
operate on the principle of pressure, the
actual and potential cautery,  and  some
styptics excepted ; the two first of which
act by forming a slough, which stops up
fhe mouths of the vessels ;  while the lat-
ter operate  by promoting their  contrac-
tion.  Let us next consider the  various
modifications of  pressure.
  M.  Petit endeavours to shew, in a dis-
sertation on  the manner of stopping he-
morrhage, printed in the Mem. de PAcad.
tie Sciences, anne"e 1731, that the different
things which have  been praised  as  infal-
lible specifics, would seldom, or never,
have succeeded  without compression. It
was always requisite, even when caustics
were  employed, to  apply compresses,
which  were  bound ton  with  sufficient
tigiitness  to resist the impulse of tlie
blood in the artery, and the  premature
separation of the eschar, occasioned by
 he actual or potential cautery. Had this
precaution not  been taken, there would
have been reason to have feared hemor-
rhage, almost invariably, and  which, in-
deed, did recur but too frequently, when
the eschar was  detached, notwithstand-
ing the pains taken to avert it by suitable
compression.   M. Petit has noticed, that
the end of the finger, gently compressing
the mouth of  a vessel, is a  sufficient
means  of stopping  hemorrhage from  it,
and that nothing else would be necessary,
if the  finger  and stump could always be
kept in this  posture.   Hence, he endea-
voured to obviate these difficulties by in-
venting a machine which securely and in-
cessantly executes the office of the finger.
This  instrument  is  a  double tourni-
quet, which, when applied, compresses,
at once, both the extremity of the divided
artery and its  trunk above the wound.
The compression on the end of the  vessel
is to be  permanent; that on the trunk is
only to be made at  the time of dressing
the wound, or when it is necessary to re-
lax the other.   An engraving and parti-
cular description of the instrument are to
be found  in Petit's memoir.
  Surgeons used formerly to  fill the ca-
vities of  the  wounds with lint, and then
make  pressure on  {he bleeding vessels,
by  applying compresses and a tight roller
over the  part.  The practitioners  of tlie
present day are too well acquainted with
the advantages of  not allowing any ex-
traneous substance to intervene between
the opposite  surfaces  of a recent wound,
to persist in the above plan.  They know,
that  the sides  of the  wound may be>
brought  into contact, and  that compres-
sion may yet be adopted, so  as both to
restrain particular hemorrhages, and ra-
ther .promote,  than retard tlie union of
the wound.
  When  the blood does not issue from
any particular vessel, but from numerous
small  ones, compression is preferable to
the ligature.  The employment  of the
latter would  render it necessary to tie the
whole surface of the wound.  The sides
of  the wound are  to he  brought accu-
rately together, and compresses are then
to be placed over tlie part, and a roller to
be  applied with sufficient  tightness to
make  effectual pressure,  but not  so for-
cibly as to produce a danger of the circu-
lation in the  ljmb being completely stop-
ped.
    If  compression  can  ever be  safely
trusted in bleedings  from large arteries,
it is  when these vessels he immediately
over a bone, against which they can be
advantageously  compressed.    Bleedings
from  the radial and temporal arteries
are of this kind. Compression is some- 
38
HEMORRHAGE.
 times tried, when the brachial artery has
 been  wounded in phlebotomy.   Here it
 is occasionally tried, in preference to the
 ligature, because the latter cannot be em-
 ployed  without  an  operation to expose
 the artery.
    When there is a small wound in a large
 artery, the following plan may be tried :
 a tourniquet is to be applied,  so as  to
 command the flow of blood into the ves-
 sel.  The edges of  the external wound
 are next to be brought into  contact.
 Then, a compress, shaped  like  a blunt
 cone, and which is best formed of a series
 of compresses, gradually increasing  in
 size, is to be placed with its apex ex-
 actly  on the situation of the w»und  in
 the artery.  This graduated compress,  as
 it  is termed, is then to be bound on the
 part with a roller.
   In this manner, I lately healed a wound
 of the superficial palmar arch, in a young
 lady  in  Great Pulteney-street.   The out-
 ward wound was very small,  and though
 the hemorrhage was  profuse, I conceiv-
 ed, that it might be permanently stopped,
 if compression could be  so  made as  to
 keep  the  external  wound   incessantly
 and firmly covered for the space of a day
 or two.   At first, I tried  a compress  of
 lint, bound on the part with a roller ; but
 this  proving  ineffectual,  1   took some
 pieces of money, from the size of a far-
 thing to that of a  halfcrown, and, wrap-
 ping  them up in  linen, put the smallest
 One accurately over the wound, so  as
 completely to cover it.  Then the others
•were  arranged,  and  all  of them  were
 firmly confined with a roller,  and the
 arm kept as quiet as  possible  in a sling.
 They were taken oft' after three days, and
 no hemorrhage ensued.
   It is  to be observed, that  the palmar
 fascia,  in this instance,  would prevent
 the compression from operating on the
 vessel;  but  the case shews, that this ar-
 tery, when wounded, is capable of he  J-
 ing, if the blood be completely prevented
 from getting out  of the external wound
 by the  proper application  of compres-
 sion.  Were the outer wound too large
 to admit of this plan, it would probably
 be necessary to dissect for the ends of the
 artery, in order to tie them.  This  ope-
 ration, however, is by no means easy;
 and, perhaps,  upon the whole,  it might
 be better to cut down, at once, to the
 ulnar  artery, and put a  ligature round
 it, though this would only certainly  stop
 the bleeding from one end of the vessel in
 the hand.
   Besides compressing the wounded part
 of the artery, some surgeons also apply a
 longitudinal compress over the  track  of
 tile vessel above the  wound,  with a view
of weakening the flow  of blood  into if.
Whatever good effect it may have in this
way, is more than counterbalanced by the
difficulty which it must  create to the cir-
culation  in  the  arm.  If tlie  graduated
compress  be  properly arranged,  an effu-
sion of blood cannot possibly happen, and
pressure  along the course of the artery
must at all events be unnecessary.
   After  relaxing the tourniquet, if no
blood escape from the artery, the surgeon
(supposing it to be the  brachial artery
wounded) should feel the pulse at_ the
wrist, in order to ascertain, that the com-
pression employed is not so powerful as
entirely to impede the circulation in the
fore-arm  and  hand.   The arm is to be
kept quietly in a sling, and, in forty-eight
hours, if  no  bleeding take place, there
will be great  reason to expect that the
case will  do well.   In another work, I
have given an engraving and description
of an instrument, invented by Plenk, for
making pressure on the wounded brachial
artery, at the bend of the arm, without
pressing upon the whole circumference of
the limb,  and consequently stopping the
circulation.   No one,  however, would
prefer compression , when large arteries
are injured, except in the kind of cases,
to which  we  have just  adverted, or in
those in which the wounded vessel can be
firmly  compressed against  a subjacent
bone.  The compresses  sometimes  slip
off", or the bandages become slack, so that
a fatal hemorrhage  may  arise.   Hence,
when this method is  adopted, the tour-
niquet should  always   remain   loosely
round the limb, ready to be tightened in
an  instant.   Sometimes  the  external
wound heals,  while the opening in the
artery remains unclosed, and an aneurism
is  the consequence.   This is particularly
apt to occur,  when  the pressure has not
been powerful enough; and, when too
great,  mortification is apt to come on:
such are the objections to placing much
confidence in  compression, except when
tlie vessels are not of considerable size.

             TOURNiaUET.

  When  hemorrhage takes place from a
large arteiy in  one of the limbs, where
the vessel can be conveniently compressed
above the wound in it, a tourniquet, ju-
diciously  applied, never fails in  putting
an immediate stop to the bleeding.
  Before the invention of this instrument,
which did not take place till the latter
part of the  17th century, surgery was
really a very defective art.  No important
operation could  be undertaken on the ex-
tremities, without placing the patient in
the most  imminent  peril; and the want 
»
HEMORRHAGE.
39
of tlie aid,  afforded by  the tourniquet,
made many wounds mortal,  which other-
wise would not have been attended with
the least danger.
  As the  first invention  of this instru-
ment has been claimed by different sur-
geons,  and   even different nations,  we
shall net take upon us to determine where
it had its origin.  But whoever was  the
inventor,  it  was first presented to  the
publick in a form exceedingly simple; so
much so,  indeed, that it seems extraor-
dinary, that its invention  did not happen
sooner.  A small pad  being placed  on
the principal artery of a limb,  a band
was applied over it, so  as  to encircle  the
limb twice.   Then a stick was introduced
between the two circles of the band, and
twisted: thus the pad  was made to com-
press with quite power enough  complete-
ly to stop the flow of blood into tlie lower
part of the vessel.
  Although, in the Armamentarium Chirur-
gicum of Scultetus; there is a plate of a
machine, invented by this author for com-
pressing the radial artery, by means of a
screw, M. Petit is universally allowed to
be tlie first, who brought the tourniquet
to perfection, by combining the circular
band with a screw, in such a manner that
the greatest pressure operates on the prin-
cipal artery.
  The advantages of the modern tourni-
quet are, that its pressure can be regulat-
ed with the  utmost exactness;  that it
epcrates chiefly on  the  point  where the
pad is placed, and where  the main artery
lies ;  that it  does not  require  the aid of
an assistant  to keep it tense : that it com-
plexly commands the flow of blood into
a limb ; that  it can be relaxed, or tight-
ened in a moment; and that, when there
is reason to fear a sudden renewal of he-
morrhage, it can be left slackly round the
limb, and,  in case of need, tightened in
an  instant.  Its utility, however, is  con-
fined to the  limbs, and as  the pressure
necessary to stop the flow of blood through
the principal  artery, completely prevents
the return of blood through the veins, its
application  cannot be made very long
without inducing mortification  It is only
of use also in putting a sudden stop to
profuse hemorrhages for  a time, that is,
until the surgeon has put in practice some
means, the effect of which is more perma-
nent.
  The ancients were quite unacquainted
with tlie use of the tourniquet, and though
some of their writers have made mention
of the ligature, they do not seem to have
known how to make proper use of it, nor
to have possessed any other certain means
of suppressing hemorrhage from wounds.
In modern times, it is easily comprehen-
sible, that, when any great operation was
undertaken, while  surgery was  so imper-
fect, there was more likelihood of harm,
than good being done to the patient.  Nor
can it be wondered at,  that the old prac-
titioners  should  have  taken  immense
pains to  invent a great  many topical as-
tringents.  But now that the ligature is
known to be a means which is safe, easy,
and  much less painful  than former me-
thods, we need no longer  search for such
remedies.
  It may, indeed,  be set down,  as  a  rule
in surgery, whenever large arteries  are
wounded, never to trust to any styptic
application whatsoever; but to have  im-
mediate recourse to the ligature, as being,
when properly  applied, the most simple
and safe of all methods.
  In order to ojualify the reader to judge
of tlie best mode of applying ligatures to
arteries,  I  shall first explain to him their
effect on these vessels, as related by Dr.
Jones.
  This  gentleman  learnt  from Mr.  J.
Thomson,  of Edinburgh,  that, in every
instance  in which a ligature is applied
around an artery,  without including .the
surrounding  parts, the internal coat  of
the vessel is torn through  by it, and  that
this  fact had been originally noticed by
Desault.   Mr.  Thomson shewed to  Dr.
Jones, on a portion of artery taken from
the human subject, that the internal and
middle coats are divided by the ligature.
(Jones, p. 126.)
  This led Dr. Jones to make  some  ex-
periments on the  arteries of   dogs  and
horses, shewing, that when a ligature is
applied with sufficient tightness round an
artery, to cut  through  its internal  and
middle coats, although  it be immediately
afterwards removed,  the vessel  always
becomes permanently impervious  at  the
part  which was tied, as  far as the  first
collateral branches above and  below  the
obstructed part.  Dr. Jones thinks it rea-
sonable to expect, that the obstruction
produced  in the  arteries of  dogs  and
horses,  in the manner  he has related,
" might  be effected by the same treat-
ment in  the arteries  of the human  sub-
ject; and, if it should  prove successful,
it might  he employed in some of the most
important cases in surgery.  The success
of the late important improvements which
have been introduced  in  the  operation
for aneurism, may perhaps appear to most
surgeons to have rendered that  operation
sufficiently simple  and safe; but, if it be
possible  to produce obstruction in   the
canal of  an artery  of the  human subject,
in the above-mentioned manner,  may it 
4<j                             HKMORl

Mot be advantageously employed in the
cure of aneurism;  inasmuch as nothing
need be done  to  prevent the immediate
union of the external wound?"   Dr. Jones
next questions, whether this mode of ob-
structing the passage of blood through the
arteries may not  also be advantageously
practised  in cases  of bronchocele > (p.
136.)
  From Dr. Jones's experiments, it ap-
pears,  that the first effects of a ligature
upon  an  artery are, a complete division
of its internal  and middle coats, an appo-
sition of its wounded surfaces,  and  an
obstruction to  the circulation of the blood
through  its canal.  There  must  be  a
small  quantity of  stagnant blood, just
within the extremity of" the artery; but
this does not,  in every instance, immedi-
ately  form a coagulum, capable of filling
up the canal of tlie artery. In most cases,
only a slender coagulunr is  formed at
first, which gradually becomes larger by
successive  coagulations of  the blood;
and hence, the coagulum is always at first
of a tapering form,  with its base at the
extremity  of  the  artery.  But,  as Dr.
Jones  remarks,  the formation  of this
coagulum is not material; for soon after
the ligature has been applied,  the end of
the artery inflames, and the wounded in-
ternal surface of its canal being kept  in
close contact  by the  ligature,  adheres,
:md converts  this  portion of the artery
into an impervious,  and, at first, slightly
conical sac.  ft is  to the effused lymph
that the  base of the coagulum adheres,
when  found to be  adherent.   Lymph is
also effused between the coats Of the ar-
tery,  and among the parts surrounding
its extremity. In  a little time, the liga-
ture makes the part, on Which it  is di"
rectly applied, ulcerate; and, acting as a
 tent, a small  aperture is formed in  the
 layer  of  lymph effused  over  the artery.
 Through this aperture, a small quantity
 df pus is discharged, as long  as the liga-
 ture remains; and, finally, the ligature
 itself also escapes, and the*little cavity,.
 which it has  occasioned, granulates  and
 •ills up,  and  the external  wound  heals,
 leaving the cellular substartce a little be-
 yond  the end  of the artery, much thicken-
 ed and indurated.   (Jones, p. 159, 161.)
   In short, when an artery is properly tied,
 the following are  the effects,  as enume-
 rated by Dr. Jones:
    1.  To cut through  the  internal  and
 middle coats of the artery, and to bring
 the wounded  surfaces  into perfect appo-
 sition.
    2. To occasion a determination of blood
 to the collateral  branches.
    3.  To allow of  the formation of a coa-
 gulum of blood just within the  artery,
provided a collateral branch is not Very
near the ligature.
  4   To excite inflammation on the in-
ternal and middle coats of the artery, by
having  cut  them  through,  and,  conse-
quently, to give rise to an effusion of
Ivmph,  by  which the wounded surfaces
are united, and the canal is rendered im-
pervious; to produce a  simultaneous in-
flammation on the corresponding external
surface  of the artery,  by  which  it be-
comes very mtich thickened with effused
lymph; and, at the same time, from the
exposure and inevitable wottndmg of the
surrounding parts,  to occasion inflamma-
tion in  them,  artd  an effusion  of lymph,
which covers  the  artery, and  forms the
surface  of the wound.
   5. To produce  ulceration in the part
of the artery,  around which the ligature
is immediately applied,  viz. its external
coat.
   6. To produce  indirectly a complete
obliteration; not only of the canal  of the
artery,  but even of the artery itself, to the
collateral branches on both sides of the
part which has been tied.
   7.  To give rise  to an enlargement of
the collateral  branches.  (Jones, p. 163,
 164.)
   Every part  of an artery is organized
 in  a similar  manner  to the  other soft
 parts, and its coats are susceptible of the
 same process of adhesion, ulceration, &c.
 as the  other parts are.   Hence, the pre-
 cautions taken to  secure the adhesion of
 other parts, should  be observed for the
 same purpose, with regard to  aft  artery.
 The vessel is put in a state to admit of ad-
 hesion  by the ligature, Which,  when pro-
 perly applied, cuts through its internal and
 middle coats, keeps their cut surfaces  in
 contact, and affords them an opportunity
 of uniting by  the  adhesive inflammation,
 as other cut surfaces do.   The immediate
 stoppage of the bleeding is merely  the in-
 cipient and temporary part of what the
 ligature has to accomplish ; it has also to
 effect  the  adhesion of the internal and
 middle coats  of the artery, which being
 the thing, on  which the permanent sup-
 pression of hemorrhage depends, is the
 most important.   The size and form  of
 the ligature,  whether completely  flat, or
 irregular, have not been, as Dr. Jones re-
 marks, sufficiently  attended  to;  nor is
 the degree of force employed in tying the
 artery, often considered.  Some surgeons,
 wishing to  guard against  the ligature's
 slipping off,  tie it with very considerable
 force;  while others,   apprehensive  lest
 they should  cut through  the artery, or'
 occasion too  early a separation of the li-
 gature, draw it only sufficiently tight to
 prevent the escape of any blood.  A broad 
HEMORRHAGE.
41
.fiat ligature is not likely to make such a
 wound in the internal and middle coats
 of the artery,  as is most- favourable to ad-
 hesion, because it is scarcely possible to
 tie  it smoothly round the vessel, which is
 very  likely  to be thrown into  folds, or
 puckered by  it, and, consequently, to
 have an irregular bruised wound made In
 its  middle and internal coats.  By cover-
 ing also a considerable  space of the ex-
 ternal coat, it may destroy the very vessels
 which pass on it in their way to the  cut
 surfaces of the inner coats, and  thus ren-
 der them incapable of inflaming.  Even
 supposing the wound to unite, still such
 a ligature  may cover that  part of  tlie
 external coat, which is directly over  the
 newly-united  part, and, consequently, as
 soon as it has produced ulceration through
 the external coat, it will cause  the same
 effect on the newly-united parts, and, of
 course, secondary hemorrhage. (Jones,
 p. 168.)
  When a  ligature  is  of an  irregular
 form, it is apt to cut through the internal
 and middle coats of an artery more com-
 pletely at some parts than  others;  but
 these coats must be perfectly cut through,
 in order to produce an effusion of lymph
 from  the inside of the vessel, which seems
 to adhere only at its cut surfaces.
  Also, when the ligature is not applied
 with sufficient tightness,  the inner coats
 of  the artery will not be properly  cut
 through.  Dr. Jones thinks,  the ligature
 being sometimes put on so as to deviate
 from a circle, has a tendency to produce
 secondary hemorrhage.
   Dr. Jones  thinks  ligatures are  best,
 when they are round, and very firm, and,
 he adds, diat though a very slight force
 is  necessary to cut through the internal
 and middle-coats of an artery, it is better
 to  tie the vessel more  tightly than is
 necessary merely to  cut through its inner
 coats, because the cut surfaces  will thus
 be more certainly kept in contact;  the
 separation of the ligature expedited;  and
 the danger of ulceration spreading  to
 tlie newly cicatrized part diminished.
 The  external coat  will  never  ulcerate
 through,  before the inner ones have ad-
 hered. The.limb, however, should be
 kept in a perfectly quiet state.
   I am sincerely glad to  find, that so ac-
 curate an observer as Dr. Jones, has re-
 futed the idea, that ligatures occasionally
 slip off the vessels, in consequence of the
 violent impulse of the  blood.  In fact,
 the blood does not continue to be  impel-
 led against the  extremity of the  artery
 with  the same impetuosity with  which
 it circulated  through tlie vessel before it
 was tied.  The blood is immediately de-
      Vor, II.
termined into the collateral branches, nor
is there any pulsation for some way above
the ligature.
  Dr.  Jones much  more rationally im-
putes  this occasional occurrence, either
to the clumsiness of the ligature, which
prevents its lying compactly and securely
round the artery;  or to  its not  having
been  applied with sufficient tightness;
or to its having that very insecure hold
of the vessel, which the deviation from
the  circular application must occasion.
(P. 173.)
  Dr. Jones is of opinion, that, in cases of
aneurism, in which the artery has  only
been tied with one ligature, and left un-
divided, and in which secondary hemor-
rhage has arisen, that this has most  pro-
bably  been  owing, either to a  diseased
state of the artery ;  to  various contriv-
ances  for compressing a large portion of
the  vessel,  or  having  a loose  ligature
above  the one, which is tied; or, lastly,
to not tying the artery sufficiently tight
to cut through the internal and middle
coats,  so as  to tit them for adhesion,  but,
so as to cause a gradual ulceration through
them,  and,  of course,  bring on hemor-
rhage,  which returns with  greater vio-
lence, as the  ulceration advances.  (P.
176.)
  Dr. Jones seems to consider, that the
advantage of the retraction of tlie  divided
artery within the cellular membrane, is
compensated, in the case of the undivided
artery, by the speedy and profuse effusion
of  lymph,  which  takes place  over and
round the  vessel,  at the tied  part, and
even covers the  ligature itself.  * How-
ever, he admits the objection,' urged  by
Mr. Abernethy, to using only one ligature,
viz. that the vessel cannot be tied, where
it lies among its  natural connexions,  or
if tied in this manner either at the upper,
j>v  lower part of the wound, the  hemor-
rhage will proceed from that part of the
vessel, which has tlie detached portion of
the artery for its extremity.  This gentle-
man concludes  this point, with allowing
it to be safest and best to apply two liga-
tures,  and to divide the artery between them.
P. 179. See Aneurism.  Another cause of
secondary  hemorrhage  is  by including
other  parts  in the  ligature, together with
the artery,  by doing which, the division
of the inner coats of the vessel  may be
prevented.                     •
   In  the  valuable  publication  of Dr.
Jones's, to  which  we have  so freely  ad-
 verted, some secondary hemorrhages  are
 also imputed to the hidden separation, or
 laceration of the recently united parts 6f
 an artery,  by premature and  extraordi-
 nary exertions of the patient. Hence, he
     F 
42                              BExMOR]

strongly insists on  kecpiflg a  limb,  in
which a large artery has been  tied, per-
fectly at rest.
  We shall conclude our remarks on the
ligature with a few practical rules.
  1. Always tie a large artery, as sepa-
rately as possible, but still let the ligature
be  applied to a part of the vessel, which
is close to where it lies among its natural
connexions.
  Besides the  reasons for this practice,
already specified, we may  observe, that
including other substances in the ligature
causes immense pain, and a larger part of
a wound to  remain disunited.  The liga-
ture  is also apt to become loose, as soon
as the substance between it and the artery
sloughs,  or ulcerates.  Sometimes  the
ligature thus  applied, forms  a circular
furrow in the flesh, and remains a tedious
time, incapable of separation.
   The blood-vessels being thus organized
like other parts, the healing of the wound-
ed artery can only take place favourably,
when that  part of the vessel, which is
immediately contiguous to the  ligature,
 continues to receive a due supply of blood
 through its vasa vasorum, which are rami-
 fications of the collateral arteries.  Hence,
 Wie disadvantage of  putting  a ligatur^
 round the middle of a portion of an artery,
 which  has  been separated  from its sur-
 rounding connexions.   Hence, the utility,
 however, of making the  knot, as closely
 as possible  to that part of the vessel which
 lies undisturbed among the surrounding
 flesh.
    Small arteries neither allow nor require
 these minute  attentions to the  mode of
 tying them.
    2. When a divided artery is  large,
 open-mouthed, and very visible, it is best
 to take hold of it, and raise its extremity,
 a little way above the surface of the wound
  with a pair of forceps.  When  tlie vessel
  is smaller, the tenaculum is the most con-
  venient instrument.
    3. While one surgeon holds the vessel
  in this way, another is to place the noose
  of a lig;.ture round it, and tie it according
  to the above directions.  In order that
  the  noose may not rise too high, and even
  above the mouth of the artery, when it is
  tightened, the ends of the ligature must
  be  drawn  as horizontally as  possible,
  Which is best done with the thu b;>s.  A
  knot is next to be made.
    4. Ligatures always operating in wounds
  as extraneous bodies, and one  end  of each
  being sufficient for its removal, the other
  should alwaj> be cut off close to the knot,
  and taken away.
    5. "VMien a large artery is either par-
  tially divided, or completely divided, two
  ligatures, one to the upper* th* other to
the lower part of the vessel, are common-
ly necessary, in consequence of the anas-
tomosing branches conveying'the blood
so readily into the part of the artery most
remote from the heart, as soon as the first
ligature has been applied.
  6.  When  a large artery is  only punc-
tured ; when compression cannot be judi-
ciously tried; and when the hemorrhage
continues;   the vessel must be first ex-
posed by an incision,  and then a double
ligature  introduced under it, with the aid
of an eye-probe.  One ligature is to be tied
above; the other below the bleeding ori-
fice ; with due attention to the principles
already advanced.
  7.  Ligatures usually  come away  from
the largest  artery ever tied, in about a
fortnight, and from moderate-sized  ones
in six  or seven days.  When they con-
tinue attached  much beyond the  usual
period, it is proper to draw them  very
gently every time the wound is dressed,
for the  purpose of accelerating  their de-
tachment.   Great care, however,  is  re-
quisite  in  doing this;  for, as Dr. Jones
remarks, as long  as  the ligature  seems
firmly attached, pulling it rather strongly
must act, more or less, on the recently
cicatrized extremity of the artery, which
is not only contiguous  to  it, but is  still
united to that portion of the artery, (the
external coat) which detains the ligature.
(Jones, p. 162.)
  For information concerning hemorrhage,
consult  Petit's  Memoirs, among those of
VAcad.  des  Sciences for the years 1731,
 1732—1735.- Morand sur le Changement,
qtri arrive aux Arteres couples, 1736: Pou-
 teau's  Melanges  de  Cfnrurgie:  Gooch's
 Chirurgical Works, Vol. 1:  Kirktand's Es-
say  on the  Metliod of suppressing Hemor-
 rhages from divided Arteries; White's Cases
in Surgery: J. BeWs Principles of Surgery,
 Vol. 1:  Purtie  Chirurgicale  de I'Encycl.
 Meth.f  Larrey's Me"moires  de  Chirurgie
 Militaire, Tom. 2, p. 379.   Pelletan's Clin-
 iqne Chirurgicale, Tom. 2. p 240, &c. Me-
 moire  EUmentaire sur les Henwrrhogies.
 Richerand's  J\i'osographie  Chirurgicale,
 Tom. 4.  Sect, snrles Maladies des Arteres,
 p. 31,  &c. Edit. 2.  Levtilli, JYouvelle
 Doctrine Cliirurgicale,Tom 1, Chap. 9. and,
 particularly, Jones on the Process employed
 by JVature, in suppressing the Hemorrhage
 from divided and punctured Arteries, 1805.
   HEMORRHOIDS,  (from «<V, blood,
 and '%i»,  to flow.)   Hxmorrhoides.  Piles.
 The etymological meaning of the word is
 evidently only a discharge of blood.   Sur-
  geons,  however,  sanctioned by long  cus-
  tom,  always imply  by the term, hemor-
  rhwdi; either a bleeding from the veins of
  the lower part of the rectum, or else a
 considta-able distention of these vessels, 
HEMORRHOIDS.
4-r
so as to form tumours, but quite unattend-
ed with hemorrhage.   When the dilated
veins do  hot bleed,  the  swellings  are
called blind piles;  but, when they are at-
tended  with  occasional  discharges  of
blood, they are named open piles.   These
tumours vary in number, size, form, and
situation : some are external, others inter-
nal  In general, tlie inconvenience which
they occasion, is  very supportable ; but,
sometimes  they  bring on  very  serious
complaints, either by bursting and dis-
charging blood so profusely as dangerous-
ly to reduce the  patient; or by exciting
inflammation of the adjacent parts, and
causing abscesses and fistulae;  or, lastly,
by becoming strangulated by the contrac-
tion of tlie sphincter ani, so as to occasion
very acute  pain.   Piles,  which bleed but
little, are  not of much consequence; but
those which bleed profusely, cause vio-
lent pain, or which induce inflammation,
and all its effects, demand the greatest
attention.    Lieutaud makes mention of a
person, who lost  three quarts of blood
from some  open  piles in the course of a
couple of days;  and  the heretic  Arius,
and the  celebrated philosopher Coperni-
cus are said to have bled to death in this
manner.
  When piles are situated far  up in the
rectum, they are commonly less painful,
than when low down.   In the former case,
the  veins  are  surrounded by soft and
yielding substances, which do  not make
any  painful pressure  on tlie swellings;
but, piles, situated towards the anus, are
apt to suffer a very painful  constriction
from the  action of the sphincter  muscle.
Hence, when such tumours are very high
up in the  rectum, the patient  has some-
times no warning of lus disorder, till he
discharges  blood from the rectum, and,
so violent a bleeding may at  once ensue,
as to prove fatal.
  With regard to the cause of hemor-
rhoids, any thing capable of retarding, the
return of blood through the hemorrhoidal
veins,  may occasion the  disease.  The
pressure of the gravid uterus, costiveness,
and the frequent retention of hardened
feces in the rectum,  are  very frequent
causes.   Persons,  who  lead  sedentary
lives, are  often troubled with the com-
plaint.  From  what has been stated, we
may easily discern the reason, why women
are more  subject to piles,  than men are,
though the disease is so common, that the
Jitter  are also very frequently troubled
with it.
  The pressure of an enlarged liver, or
of water accumulated  in the cavity of the
peritoneum, is said sometimes to be the
occasion of piles.
   When  these tumours are produced by
the pressure of the  gravid uterus, no
cure can be expected till after delivery,
when one generally follows spontaneously.
Also, when piles are an effect of dropsy,
they can only get well, after tlie  pressure
of the  fluid in the abdomen has been re-
moved by tapping. Gently laxative medi-
cines,  and an horizontal position of the
body, commonly alleviate the uneasiness
resulting from hemorrhoids.  The appli-
cation  of an ointment, composed  of equal
parts of the powder of oak-galls,  and of
elder-ointment, or hog*s lard, contribute
to the same beneficial effect. Applying
warm  water  to  the  tumours, by  means
of a bidet, or  semicupium, is also fre-
quently productive of great ease.  When
piles  are constricted  by the sphincter
ani muscle, the pain thus  arising,  may
often be at once removed, by pushing the
swellings  with the  finger a little higher
up the rectum.  Leeches applied  to the
vicinity of the anus, and puncturing the
dilated hemorrhoidal vessels with a lancet,
for the purpose of taking  away  blood,
are  measures occasionally employed to
procure ease. Mr. Ware seems to  give
the preference to leeches;; Petit preferred
the lancet.
  When the  number  and size of hemor-
rhoids are so considerable,  as materially
to obstruct the  discharge  of the  feces;
when  they are very painful, and subject
to profuse bleedings; when the patient is
disabled from following his  usual occu-
pations ; and when all  the above  means
are not  of sufficient avail, the^  surgeon
should recommend the  removal of the
tumours.
  Extirpating piles with the actual  cau-
tery and caustics, as practised by the old
surgeons,  is now very properly altoge-
ther relinquished by  modern practition-
ers.   The only plan ever followed  in the
present state of surgery, is either to cut
tlie tumours off  with a pair of scissars or
knife,  or to apply a tight ligature round
their bases, so as to make  them slough
away.
  When piles are to be cut off, and they
are not sufficiently  visible,  the patient
must first strain, as at  stool, in order to
make the swellings more apparent. With
the aid of a pair of dissecting  forceps,
the skin, covering the  hemorrhoids, is
then  to be separated from them wfyh
the knife,  but not cut away,  and the tu?
mours are to be removed. Sabatier states,
that saving  the skin is very essential;
for,  any hemorrhage  which may arise,
can then be more easily suppressed ;  and,
when there are several hemorrhoids to be
extirpated, the  loss of  substance about
tlie anus will be  less,  and, of course, the
patient will not be so liable to a contrac- 
44
HEMORRHOIDS.
tion of this part,  which is sometimes a
very great affliction.
  Mr. Ware thinks  it unnecessary to re-
move all the swellings, when there are
several of them. He remarks, that though
the  number  of hemorrhoidal tumours,
protruded through the anus, is often con-
siderable, yet the pain which the patient
suffers, is not produced equally by all of
these;  but, that he will point to one, or
at most to two, of the tumours, whence
all his pain proceeds. These will be found
to be much harder  and more  inflamed
than the rest;  but, generally smaller and
less prominent,  protruding only just low
enough to be compressed by the sphincter
muscle.
  Hence,  Mr. Ware  contends, that cut-
ting off the whole number of hemorrhoids
with a  scalpel, or scissars, and  tying a
ligature round them, in order to make
them die and fall off, are unnecessary. He
says, we have only to direct our attention
to the hard inflamed tumour, which is the
cause  of  the  pain,  and  which  is  not
unfrequently situated in the centre of the
rest.  This is often  not larger than the
end of the  little finger, and the removal
of it almost instantly abates the pain, and
soon makes the rest of the tumours, col-
lapse and disappear.  Mr.  Ware operates
as follows : having secured with a com-
mon dissecting-hook, or forceps, the little
hard tumour, which is often in the middle
of the  rest, and much darker coloured,
lie snips it off, as close to its basis as pos-
sible, with a sharp pair of curved scissars.
The pain is trifling,  and the hemorrhage
60 slight, that Mr. Ware  says,  he  has
rarely had occasion to use any application
to check it.  If the hemorrhoids are con-
stantly protruded, the operation  may he
performed at any time; but, if they only
appear  after the  feces are voided,  that
opportunity must be taken.
  When the pain of hemorrhoids is not
violent, but there is  a constant distress-
ing uneasiness, with frequent returns of a
profuse debilitating hemorrhage, Mr.Ware
states,  that his method of operating will
frequently produce a radical cure.
  The  excision of  piles is occasionally
followed by a very dangerous bleeding,
as a case, related by Mr. Petit, confirms.
A patient had some  hemorrhoids, which
were supposed to be external ones, though
in f..ct they were not, and had only be-
come  protruded.  Almost immediately
alter they had been cut off, the skin which
had  supported  them, became drawn in-
ward.   An inward hemorrhage ensued,
which could not be suppressed, and prov!
ed  fatal in less  than five hours.   The
rectum and colon were found full of black
coagulated blood.                    '
   After the operation, Mr. Ware advises
 a thick compress to be applied, wet either
 with  cold brandy and water, or with a
 cold satumine lotion, and retained on the
 part with  the T bandage.' The patient
 should be kept quietly in a cooler tem-
 perature than usual, and be  enjoined to
 eat and  drink nothing of  a stimulating
 quality.
   Certainly, if the bleeding should prove
 troublesome, and  proceed from vessels
 within the rectum,  tlie  best plan would
 be to distend  the  gut  with a  suitable
 piece of  sponge, so as to make  pressure
 on the wound, observing to adopt at the
 same time the means above recommended.
   Tying  hemorrhoids is free  from the
 danger of hemorrhage;  but, still it has
 its inconveniences, though ihey are not
 constant ones.  Petit frequently practised
 this method, without any ill effects.  In
 other instances, he  had  reason to repent
 having adopted it.   A woman, for whom
 he had tied three hemorrhoids with nar-
 row pedicles, which were favourably situ-
 ated  for the operation,  did  not at first
 experience a great  deal of pain.  How-,
 ever, five hours afterwards  he was in-
 formed,  that she  suffered violent  colic
 pains, .which extended along the colon.
 The woman was bled four times, without.
 relief.  At last, Petit cut the ligatures,
 which could not be loosened,  in conse-
 quence of their being concealed so deeply
 in the substance of the swollen parts. The
 pain very soon subsided. "The  ligatures
 had only been  applied four and twenty
 hours, but the piles had become black,
 and the skin covering their bases was cut
 through.   Petit removed them, without
 the least effusion of blood.
   M. Petit also relates a case, in which a
 patient, after having some piles tied, died
 of symptoms resembling those, which take
 place in cases of strangulated hernia, not-
 withstanding the ligatures were  cut as in
 the foregoing instance.   After these two
 cases, Pent abandoned the  plan  of curing
 hemorrhoids by tying them.
   I believe, on the whole,  that it is best
,to remove hemorrhoids with a knife un-
 less they are situated high up the rectum,
 where the veins  are of large size, and
 likely to bleed profusely.  If a tumour so
 situated  should  absolutely  require re-
 moval, a ligature might  be put  round its
 base with the aid of a double cannula,  in
 the  way  we shall relate in speaking  of
 Polypi.   When the  base of the tumour,
 however, is large, admits of being brought
 into view,  and the surgeon prefers  tying
 it, he should pass a  needle, armed with a
 strong double ligature, through the root
 of the hemorrhoid, and tie one part  of
 this ligature firmly over one side of the 
HERNIA.
45
swelling, and the other over the opposite
one.   When the  base  of the tumour  is
narrow, and the ligature is preferred, the
part may be tied at once, without passing
a double ligature through its middle.
  As  piles very seldom  prove fatal, an
opinion has commonly prevailed, that they
are of a salutary, or critical nature.  They
have  not unfrequently been  regarded, as
an evacuation, by which some peccant, or
morbific matter,  is thrown off from the
body  ; and hence, patients have frequently
been taught to submit to all the pain, and
uneasiness, which the disease occasions,
rather than seek  a cure.  This opinion,
however,  is neither founded upon  impar-
tial and mature observation, nor upon
solid  reasoning; for, granting that there
was any morbific matter in the body, it is
impossible to explain why it should be
collected in the blood,  which  fills the
dilated veins about the rectum, more than
any where else.
   For information on  hemorrhoids, con-
sult  VEncyclopidie Methodique;  Partie
 Chirurgicale.  Sabatier, De  la Midecine
 Optratoire, Tom.  2.  Latta's System  of
 Surgery,  Vol. 2.   Ware on  the Treatment
 of Hemorrhoids. Abernethy on Hemorrhoidal
 Diseases in his Surgical Works, VoU 2, p.
 231,  &c.
   HE'RNIA.  (from epm, a branch, from
 its protruding  forward.)   Surgeons un-
 derstand by the term hernia, a tumour,
 formed by the protrusion of some of the
 viscera of the abdomen, out of that cavi-
 ty, into a kind of sac, composed of the
 portion of peritoneum, which is  pushed
 before them. However, there are certainly
 some cases which will not be compre-
 hended in this definition; either because
 the parts are not protruded at all, or have
 no hernial sac, as the reader will  learn in
 the course of this article.

      GENERAL nF-HIAUKS OW  HEimi.E.

   "  The  brilliant progress, which sur-
 gery has  made in  modern times, (says
 Scarpa)  is, properly  speaking, only  the
 results of pathological anatomy, that is to
 say, of exact comparisons of tlie natural
 state of our organs  with their different
 diseases,  which may depend upon  an
 alteration of texture, a derangement of
 functions, a solution of continuity, or a
 change of  situation.  It  is from these
 important results, that the  most  rational
 curative  methods, with which  modern
  surgery is enriched, are deduced as so
  many corollaries; methods, to which we
  are  also  indebted for the  perfection  of
 operations.
    - There arc indeed a certain  number
of surgical operations, for the prompt and
safe execution of which, mere anatomkcal
knowledge  will suffice;  but,  in many
others, the surgeon cannot promise him-
self success, even though he be well ac-
quainted  with anatomy,  unless  he has
particularly studied the numerous changes
of position, and alterations of texture, of
which the parts, upon which he is about
to operate, are susceptible.  If he has not
the requisite information  upon all  these
points, false appearances may deceive his
judgment, and make  him commit  mis-
takes, sometimes of a very serious and
irreparable kind.
  " In order to have a convincing  proof
of this truth, it will be sufficient  to take
a view of the different species of hernix,
and their  numerous complications.  As-
suredly, no anatomist would believe, that
the  intestine caecum, naturally fixed in
tlie right ilium, and the urinary bladder,
situated at  the  bottom  of the  pelvis,
could undergo, without  being torn,  so
considerable a displacement as  to pro-
trude through the  abdominal ring, and
descend even into the scrotum; that the
 same intestine the caecum could pass from
the  right  iliac region  to the  umbilicus,
so  as to protrude at this opening, and
form an umbilical hernia; that the right
 colon could  have been seen  protruding
 from the abdomen at the left  abdominal
 ring, and the left colon through the right
 one ; that the liver, the spleen, and ovary
 could sometimes be the  parts contained
 in the umbilical, inguinal, and  femoral
 herniae; that the caecum could engage
 itself within the colon, and even protrude
 at the anus;  that  the  stomach, forced
 through the diaphragm,  could form a
 hernia within the chest; that the omen-
 turn,  or intestine, or both these parts to-
 gether, could sometimes make their escape
 from the belly through the foramen ovale,
 or  sacro-ischiatic notch, of the pelvis ;
 that a noose of small intestine, after being
 engaged in the abdominal ring, or under
 the femoral arch, could suffer the most
 violent strangulation, without the  course
  of the intestinal matter being intercepted;
 lastly, that, in certain circumstances, the
  intestine and omentum could be  in  im-
  mediate contact with the testicle, within
  the tunica vaginalis, without the least  la-
  ceration of this latter membrane.  These
  and several  other  analogous facts,  says
  Scarpa, are so surprising, that they would
  yet  be regarded as incredible,  had they
  not  been proved by numerous observa-
  tions on  individuals  affected with her-
  nia:  their possibility,  (repeats this ex-
   Eerienced professor) would not even have
   ecu suspected either by the anatomist, 
46

or physiologist.'1
Hernies, Fref)
HERNIA
(Sec Scarpa's TraitC dee
CAUSES OF HERNIS.
  The places, in which these swellings,
most frequently make their appearance,
are the groin,  the  navel, the labia pu-
dendi, and the upper and forepart of the
thigh ; they do also occur at every  point
of the anterior part of the abdomen; and
there are  several less common instances,
in which  hernial tumours present them-
selves at  the foramen ovale in the peri-
naeum,  in the  vagina,  at the ischiatic
notch, &c.  These rarer species of hernia
will  be noticed  in their proper place.
  The parts, which, by being thrust forth
from the cavity, in which they ought na-
turally to remain, mostly produce herniae,
are either a portion of the omentum, or a
part of the intestinal canal, or both toge-
ther. But, the stomach, the liver, spleen,
uterus, ovaries,  bladder, &c.  have  been
known to form the contents of some herni-
al tumours.
   From these two circumstances of situa-
tion and contents, are derived all the dif-
ferent appellations,  by which  herniae are
distinguished.  If a  portion of  intestine
only forms the contents of the tumour,  it
is called enterocele; if a piece of omentum
only, epUplocele; and  if  both  intestine
and  omentum contribute mutually to the
formation of a tumour, it is called entero-
epiplocele.  When the contents of a hernia
are protruded at the abdominal ring, but
only pass as low as the groin, or labium
pudendi,  the case  receives the name  of
bubonocele, or inguinal liernia; when the
parts descend into the scrotum, it is  called
an oscheocele, or scrotal hernia. The crural,
or femora' hernia, is the  name  given  to
that which takes place below Poupart's
ligament.  When the bowels protrude at
the  navel, the  case is named  an  exom-
phalos, or umbilical hernia; and veiUral is
the  epithet given to the swelling, when it
occurs at any  other promiscuous part of
the  front of the abdomen.  The congenital
rupture is a very particular case, in which
the  protruded  viscera  are' not  covered
with  a common hernial  sac of  perito-
neum, but are  lodged in the  cavity of
the  tunica vaginalis, in contact  with the
testicle, and, as must  be  obvious, it is
not named, like herniae in general, from
 its  situation, or contents, but from the
circumstance of its existing from the time
 of birth.
   When the hernial contents lie quietly
 in the sac, and admit of being readily put
back into the abdomen,  it is termed a re-
ducible hernia; and, when they suffer no
constriction, yet cannot be put back, ow-
ing to adhesions, or their large size in rela-
tion to the aperture, through which they
have to pass, the hernia is termed irreduci-
ble. An incarcerated, or strangulated liernia,
signifies one, which not only cannot  be re-
duced, but suffers constriction ; so that, if
apiece of intestine be protruded, the pres-
sure, to wliich it is subjected, stops the
passage of its contents onward towards the
anus, makes the bowel inflame, and brings
on a train of most alarming, and often fatal
consequences.
  The causes of herniae  are either pre-
disposing or exciting.  Of the former kind,
writers mention  a  preternaturally  large
size of the openings, at which the bowels
protrude; a.weakness  and  relaxation of
the margins of these apertures;  a preter-
natural laxity of the peritonaeum ; an unu-
sually  long  mesentery, or omentum, &c.
It is very certain, that, with regard to the
abdominal ring, the transverse tendinous
fibres, which naturally cross and strength-
en its  upper  and outer part, are  much
weaker in some subjects tlian others.  No
idea seems more prevalent in books, than,
that taking a good deal of oil with one's
food, is  conducive to the occurrence  of
ruptures. Some of the alleged pre-dispo-
sing causes, may justly excite scepticism;
but there are several circumstances which
tend to prove, that a natural deficiency of
resistance, in any part  of the parietes  of
the abdomen, is certainly a cause of this
kind.  We need only mention, how very
liable persons are, who have had the peri-
tonaeum wounded, to the present disease ;
and how much more liable  men are than
women to the inguinal liernia, owing evi-
dently to the larger size of  the abdominal
ring in the former, than tlie latter subjects.
These, however,  having a larger space for
the protrusion of the viscera, below Pou-
part's ligament,  are  more  exposed than
men to femoral herniae.
   With regard to the exciting causes, our
knowledge is involved in less doubt.  The
grand cause of this kind, is the  powerful
action of the abdominal muscles and dia-
phragm on the viscera. In feats of agility,
 such as jumping, &c. the pressure which
 the contents of the abdomen must often
 encounter,  sufficiently accounts for their
 protruding  at any part, where  the abdo-
 minal parietes  do  not  make   adequate
 resistance.   The same consideration  ex-
 plains, why herniae very  often take place
 in lifting and  carrying  heavy weights,
 running, vomiting,  straining  at stool,
 parturition,  &c.  and  in people who  in-
 habit mountainous countries. 
HERNIA.
47
  This diminution of the capacity of the
abdomen, by the action of the abdominal
muscles  and diaphragm,  on many occa-
sional exertions, must take place  in every
one, by reason of  the common habits and
necessities of life.   But, as only a certain
number of persons meet with the  disease,
it is fair to infer, that, either the exciting
causes must operate with greater force in
thtm than in the generality of people,  or
else their  abdominal  parietes have not
been  capable  of  the ordinary  degree  of
resistance.   Many patients who meet with
herniae,  in   making violent  efforts and
exertions, may be in the former  circum-
stance;  while others, who  have their
viscera protruded from such trivial things
as coughing, sneezing, crying, &c. must
be considered as being under the influence
of some predisposing cause.  A gentle-
man, who has gained great honour by a
late publication on hernia, remarks,  that,
" herniae, which  originate in predisposi-
tion,  generally come on gradually, and
almost imperceptibly; while those which
are produced  by bodily exertion,  are
formed suddenly, and by ■ the immediate
action of the exciting cause.  The oc-
currence of the complaint is often indi-
cated, in the first instance, by a  fulness,
combined with a  sense of weakness, about
the abdominal ring.   The swelling is  in-
creased by  any action of the respiratory
muscles, and disappears on pressure, and
in the recumbent position of the body.
It gradually finds its  way  through the
 tendon of the external oblique  muscle,
into  the groin,  and afterwards  into the
 scrotum.  When  a hernia  takes  place
 suddenly, it is generally attended with a
 sensation of something giving way at the
 part, and   with  pain."   ^Lawrence on
 Hernia; 1807 ;j&. 11.)
    Upon  the  subject  of  the  immediate
 cau^e of herniae,  it is observed by Scarpa,
 that several of the most celebrated mo-
 dern surgeons, as, for instance,  Warton,
 (Adenograph. cap. 11.) Benevoli, (Disserta-
 zioni Chinirgiche, 1.)  Rossius, (Acta JVaf.
 cur, Tom. 2, Obs. 178.) Brendel (de hemi-
 arum natalibus) and Morgagni, (de sed. et
 cans. morb. epist.  43, art.  13,) consider a
 relaxation  and elongation of the mesen-
 tery, as the principal cause of herniae in
 general, and  of the bubonocele  in parti-
 cular.   Hence it  happens, say they, that
 the whole  mass  of intestines, or  only a
 portion  of  an  intestine, descends against
 the  inner  orifice of  the inguinal ring,
 comes  into  contact  with  this  opening,
 and gradually makes its way out  of the
  abdomen.  In examining  this  patholo-
  gical point  Without  prejudice,  it  flfin-
  contestable,  says Scarpa, that  an intes-
  tine cannot be moved beyond its natural
  limits, unless that part of the mesentery,
which retains and fixes the  bowel in its
proper place, be at the same  time elon-
gated.   But, it does not follow from this,
that a relaxation of the" mesentery must
precede the  displacement of the intes-
tii.e.  It appears to Scarpa much more
probable, that these two events are simul-
taneous, and  depend  upon one and the
same cause.
  '• In  the healthy state, (observes this
interesting writer)  the abdomen, consi-
dered  altogether,  is  submitted to two
opposite forces,  which reciprocally  ba-
lance each other.  One is the pressure  of
the  viscera  against the  abdominal  pa-
rietes ; the other is the reaction of these
same parietes  upon  the  viscera, which
they contain.   If these two forces were
in perfect equilibrium in  all individuals,
and under all the circumstances  of life,
we should not be in the least subject  to
herniae.  tf, when the equilibrium has
been broken, every point  of the  parietes
of the belly were to yield equally to the
impulse of the viscera, an increase of tlie
volume of the whole abdomen would  be
the consequence; but,  a true hernia would
never  happen.  The  cavity  of  tlie ab-
domen is  always completely full.  The
containing  and  contained   parts react
upon, and reciprocally compress one an-
other.  It is by the effect of this moderate,
but equal and unremitting pressure, that-
all the viscera mutually support  each
other.   Without it,  the ligaments of the
liver,  those  of the spleen,  and the va-
rious membranous bands of  the intestines
in  general, would  only be  feeble means
 for fixing such  parts  in their respective
 situations.  But, there are certain points
 of the abdominal parietes, which natu-
 rally present much less  resistance, than
 others, and which  react with much less
 power against the  pressure  made  from
 within outwards by  the abdominal vis-
 cera.  Such is particularly the part, which
 extends from the  pubes  to the anterior
 superior  spinous  process of the ilium.
 This  relative  weakness of some  points
 of the abdominal parietes is very marked
 in certain  individuals, in consequence of
 a defect of organization.  It may also be
 increased by internal  or external causes,
 which are  as various as  they are nume-
 rous.   W hen, in one  of these cases, the
 pressure made by the viscera  is unusually
 increased, as happens in a violent effort,
 a defect in the equilibrium between the
 two forces  above mentioned  is occasion-
 ed; tlu-t is to say,  the reaction of the
 abdominal  parietes is no longer propor-
 tioned,  at  least  at  certain  points, to
 the force  of the  impulse of the  viscera.
 The conjoined powers of the abdominal
 muscles, diaphragm, and levator ani, are
 then  directed'and concentrated against 
46
HERNIA.
the most feeble point of the abdomen, to-
wards  which  they  propel the  nearest
viscus, or  th-t, which,  from its move-
ableness, is the most liable to displace-
ment.  If such viscus should  happen to
be the "noose  of an intestine, it is evi-
dent, that the power, which  tends to
make it protrude from the belly, must at
the same time act upon the corresponding
portion of the  mesentery; and the intes-
tine, in passing  through the parietes of
the abdomen, drags the mesentery after
it, and makes this  membrane yield and
become elongated.   AVhen  the displaced
viscera meet with little resistance on the
part of the parietes of the  abdomen, the
hernia is quickly formed,  and the elon-
gation of  the  mesentery  occurs  with
equal cele/ity.   We have an example of
this  in  the Inguinal  congenital  hernia:
in this  case,  the intestine is, in  some
measure, precipitated  into a  sac previ-
ously prepared for its reception.   On the
contrary, in the ordinary  inguinal her-
nia, a totally different disposition of the
parts renders the progress of the disease
much slower.   In  most instances, the
lieriiia is  not  formed immediately' the
equilibrium between  the impulse of the
viscera and the reaction of the abdominal
parietes, is broken.   But  in  the groin,
a slight elevation is first observed, which
reaches from the anterior superior spinous
process of the ilium to the  inguinal ring.
Some time afterwards, when the intes-
tine has made its appearance on  the out-
their   cause  is  owing  to a  laxity and
weakness of the parietes of the vagina,
which not being capable  of making any
further resistance to the pressure of the
viscera situated in the cavity of the pei-
vis, at length  suffer these parts  to pro-
trude.
  "With respect to  the  second propo-
sition, that  during the  formation of a
hernia,  the  combined  force of  all the
abdominal muscles is, as it were, directed
and concentrated against the most feeble
point  of the parietes, we see a  proof of
it in a fact that occurs to our observation
every day.  In  order to  convince  our-
selves of Nthis, it is  enough  to notice the
individuals afflicted with herniae: if they
cough, or sneeze; in a word, if they make
the slightest  effort,  they instantly find
the size  of  the swelling  increased, and
hasten to support the part with their hand.
During the slightest  shocks,  which ren-
der the herniae  larger, it is also  indis-
putable, that the mesentery is elongated
in  the same proportion as  the  intestine
protrudes.   All the viscera have such a
tendency to be displaced and carried  to-
wards the weakest  point  of the  parietes
of the abdomen, that even  those, which
are naturally  the most distant from  it,
and are the most firmly fixed by the folds
of the mesentery, may  in their turn de-
scend into the herniae. Anatomical know-
ledge alone would never have ledusto have
a suspicion of the possibility of these oc-
currences.  Sandifort  and  Paletta  have
side of the ring, the enlargement of the „ found, in ah umbilical hernia, the caecum,
                                        with  a portion of the  ilium  and colon.
                                        ( Obs.  Pathol, cap. 4, & Nova  Gubernaculi
                                        testis Descriptio.)  Mauchart, Camper, and
                                        Bose,  have met  with the caecum in  an
                                        inguinal hernia  of the left  side.   (De
                                        Hern.  Incarc. in Halleri Disput.  Chirurg.
                                        Tom. 3.  Demonstrat. anat. patholog. lib. 2,
                                        p. 18, & Animadvers. de Iiern.inguin.p. 5.)
                                        Lassus has seen the left colon protrude at
                                        the right inguinal ring.  (M6decine  Opi-
                                        ratoire, Tom. 1, p. 173.)  R* it be proved
                                        by all these facts, that such  viscera; as
                                        are the most closely united to the great
                                        sac of the peritoneum  and neighbouring
                                        parts, are  nevertheless  liable  to  form
                                        herniae; and if such displacements  can-
                                        not happen without a  considerable elon-
                                        gation of the membranous bands fixing
                                        these bowels in their natural situation,
                                        how can we refuse to admit, that a noose
                                        of intestine, pushed by degrees through
                                        the  inguinal ring, drags  along with it
                                        the corresponding portion of the mesen-
                                        tery ?  In order to  explain   this event,
                                        there is  no necessity  for  supposing a
                                         partial  relaxation  of  the  mesentery."
                                         (Traite"  Pratique  des  Hernies, Par A.
                                         Scarpa, trad, de I'ltalien, p. 37-—43.)
hernia, and the elongation of the mesen
tery, make much  more rapid, though al-
ways simultaneous progress.
  "Numerous   practical  observations,
(says Scarpa) concur in proving the fore-
going account, that we must not search
for the immediate cause of herniae in the
relaxation of the  mesentery, but  rather
in  a  want of  equilibrium between the
pressure of the viscera and the resistance
of one or several points of the abdominal
parietes.  Indeed, herniae are  seen occur*
ring from the slightest causes in infants,
in whom the  neck of the tunica vaginalis
is not speedily obliterated, and in indivi-
duals, who, from being fat have all on a
sudden become extremely thi: . Such wo-
men as have had children, are more subject
to the disease than others.  Persons also
of both sexes, who carry considerable bur-
dens, or who play upon wind instruments,
or who have suffered a forcible contusion
of the abdomen, are particularly exposed
to tlie disorder, even though there is not
the least reason for suspecting in them a
relaxation of  the  mesentery.   Vaginal
hernia;, which arises after difficult labours,
afford another proof of the  same truth; 
HERNIA.
49
  The general  symptoms of a  hernia,
which is reducible, and free from stran-
gulation, are, an indolent tumour at some
point of tlie parietes of the  abdomen ;
most frequently descending out of the ab-
dominal ring, or from just below Poupart's
ligament, or else out of the  navel;  but,
occasionally, from  various other situa-
tions,  as  will  be  presently  explained.
The swelling often originates suddenly,
except in the  circumstances above re-
lated,  and,  it is subject to a change of
size, being smaller when the patient lies
down on his back,  and  larger when he
stands up,  or holds his breath.  The tu-
mour frequently diminishes when pressed,
and grows large again when the pressure
is removed.  Its size and tension often
increase after a meal, or when the patient
is flatulent.   Patients  with hernia,  are
apt to be troubled with colic, constipa-
tion, and vomiting, in consequence of the
unnatural situation of the bowels.  Very
often, however, thev functions  of the vis-
cera seem to suffer little or no interruption.
  If the case be an  enterocele,  and the
portion of intestine be small,  the tumour
is small in proportion; but, though small,
yet, if the  gut be distended with wind,
inflamed, or have any degree of stricture
made on it, it will be tense,  resist  the
impression of the finger, and give  pain
upon being  handled.   On  the contrary,
if there be  no  stricture, and the intes-
tine suffers  no  degree  of inflammation,
let the prolapsed piece be of what length
it may, and the tumour of whatever size,
yet the tension will be little, and no  pain
will attend  the  handling  it; upon  the
patient's coughing, it will feel as if it
were blown  into; and, in general,  it  will
be  found very easily returnable.   (Pott.)
A guggling noise is often made when the
bowel is ascending.
  tf the hernia be an epiplocele, or one of
the omental kind, the tumour has a more
flabby, and a more unequal feel; it is in
general perfectly indolent,  is more com-
pressible, and (if in the scrotum) is more
oblong, and less round, than the swelling
occasioned in  the sa|ne situation  by an
intestinal hernia; and, if the quantity be
large, and the patient adult, it is, in some
measure distinguishable by  its  greater
weight  (Pott.)
  If the case be an entero-epiphcele,  that
is,  one consisting of both intestine  and
omentum,  the  characteristic marks  will
be  less clear than in either of the simple
cases; but the disease may easily be dis-
tinguished from every other  one, by any
body in the habit of making tlie examina-
tion.  (Pott, p. 28.)
  On the subject of prognosis, Mr.  Pott
Wmarks,  " that the  same kind  of  rup-
     Vot. II.
ture, in different people, and under dif-
ferent  circumstances, wears  a very vari-
ous face ; the age and constitution of the
subject, the date of the disease, its being
free, or not free from stricture, or inflam-
mation, the  symptoms  which attend it,
and the probability or  improbability of
its being returnable, necessarily producing
much variety; the degree  of hazard at-
tending this complaint will be also more
or less, as it shall happen to be circum-
tanced.
  " If  the subject be an infant, the case
is not often attended with  much diffi-
culty,  or hazard; the softness and duc-
tility of their fibres generally rendering
the reduction easy as well  as the  de-
scent ; and though from neglect, or inat-
tention, it may fall down again, yet it is
as easily replaced, and seldom produces
any mischief;  I say  seldom, because I
have seen an infant, one year old, die of a
strangulated hernia, which had not been
down  two days, with all the symptoms of
mortified intestines.
  " If the patient be adult,  and in the
vigour of life,  the consequences  of neg,
lect, or of mal-treatment, are more to be
feared than at any other time, for reasons
too obvious to need relating.  The great
and principal mischief to be apprehended,
in an  intestinal hernia,  is an inflamma-
tion of the gut, and an obstruction to the
passage of the aliment and feces through
it; which  inflammation  and obstruction
are generally produced by a stricture
made  on the intestine.   In very old  peo-
ple, the symptoms do not usually make
such rapid progress,  both  on account of
the laxity of their frame, and their more
languid circulation ; and also that their
ruptures are most frequently of ancient
date, and the passage a good deal dilated;
but then, on the  other  hand, it should
also be remembered,  that  they are by no
means exempt from inflnmm;.tory symp-
toms ;  and that, if such should come on,
the infirmity of  old age is  no favourable
circumstance in the treatment, which may
become necessary.
   " ft  the disease be recent,  and the pa-
tient young,  immediate reduction,  and
constant care to prevent its pushing out
again,  are the only means  whereby it is
possible to obtain a perfect cure.
   " If the disease be of long standing,
has been neglected, or suffered to be fre-
quently down, and has given little or no
trouble, the aperture in the abdominal
muscle, and the neck of the hernial sac,
may both be presumed to be large; which
circumstances  in general  render  imme-
diate  reduction less  necessary and less
difficult, and also  frustrate all rational
expectation  of a perfect cure-   On the 
Su                                HERNIA.
contrary,  if the rupture be  recent, or,
though old, has generally been kept up,
its immediate  reduction is more abso-
lutely necessary, as the risk of stricture
is greater from the supposed smallness of
the aperture, and narrowness of the neck
of the sac.  If the rupture be  very large
and ancient, tlie patient far advanced in
life, tlie intestine  not  bound  by any de-
gree of stricture, but does its office in the
scrotum regularly, and no other incon-
venience be found  to attend it, but what
proceeds from its weight, it will in gene-
ral be better not to attempt reduction, as
it will, in  these circumstances, most pro-
bably prove fruitless,  and  the handling
the parts  in the attempt, may so bruise
and ii'jure them as to do mischief;  but
this must  be understood to be spoken of
those only in which   there is not  the
smallest degree of stricture, nor any symp-
tom of obstruction in the intestine; such
circumstances  making  reduction  neces-
sary at all times, and in every case.
  " With  regard to the contents of  a
heniia,  if it  be a portion of omentum
only,  and  has  been gradually  formed, it
seldom  occasions  any bad  symptoms,
though  its weight  will sometimes render
it very  troublesome.  But  if  it be pro-
duced suddenly, by effort or violence, that
is,  if a considerable  piece of the caul
by accident slip down  at  once, it will
sometimes prove painful, and cause  very
disagreeable complaints ; the  connexion
between the omentum, stomach, duode-
num,  &c. being such as  to render  tlie
sudden  descent of a large  piece  of the
first sometimes productive of nausea,  vo-
miting,  colic,  and  all  the disagreeable
symptoms arising from the  derangement
of these  viscera.  When   the piece of
caul is engaged in such a degree of stric-
ture as to  prevent the circulation of blood
through it, it will sometimes, by becoming
gangrenous, be tlie occasion of very bad
symptoms, and even of death,  as I* have
more  than once seen; and thus, as  a
mere omental hernia, it may sometimes be
subject to great hazard.  But even though
it should never be liable to the just men-
tioned evil, that is, though' the  portion
of the caul should remain uninjured in
tlie scrotum, yet it renders the patient
constantly liable to hazard  from another
quarter: it makes  it every moment pos-
sible  for a piece of intestine to slip into
tlie same  sac,  and thereby add to  the
case all the trouble and all the danger
arising from an intestinal rupture.  It is
by no means an uncommon thing for  a
piece of gut  to be added to a rupture,
which had for many jears  been merely
omental, and for that piece to be strangu-
lated, and recjLue immediate help.
   " An old omental hernia, is often ren-
dered not reducible, more by an altera-
tion made  in  the  state of the prolapsed
piece of caul, than  by its quantity.  It
is very common for that part of tlie omen-
tum which  passes  through the neck  of
tlie sac,  to  be compressed into a  hard,
smooth body, and lose all appearance  of
caul, while what is below in the scrotum
is  loose and  expanded, and enjoys its
natural  texture ;  in this case, reduction
is often  impossible, from the mere figure
of the part: and 1 have so often seen this,
both in the living and the dead, that I am
satisfied, that for  one omental  rupture,
rendered irreducible by adhesions, m any-
more become  so  from the cause above-
mentioned.
  " In the sac of old omental  ruptures
that have been long  down, and only sus-
pended  by a bag truss, it is no  very un-
common thing to have a pretty consider-
able quantity of fluid collected : this,  in
different slates and circumstances of the
disease, is of different colour and consist-
ence, and seldom so much in quantity  as
to occasion any particular attention  to
it; but  on the other hand, it sometimes
is  so much  in quantity as to  become an
additional disease  to  the original  one
I have more than  once been  obliged  to
let  it out, in order to remove the incon-
venience arising from its weight, and the
distention of the  scrotum, which I have
also seen become gangrenous  by the ne-
glect of this operation.
  " If the  hernia  be  of the intestinal
kind, merely,  and the  portion of gut be
small, the  risk is  greater, strangulation
being more likely to happen in this  case,
and more productive of mischief, when it
has happened:  for the smaller the  por-
tion  of  gut is  which is  engaged, the
tighter  the  tendon  binds, and the  more
hazardous  is  the  consequence.   I  have
seen a fatal gangrene, in a bubonocele,
which had not been formed forty-eight
hours, and in  which the piece  of intes-
tine  was little more than half ah  inch.
There  are  few practitioners,  who  have
^een business, but know the truth of this ;
but perhaps the reason of it is not  suffi-
ciently explained to  the  unknowing:  it
is  this;  when a considerable  portion  of
intestine passes out  from the  belly  in a
hernial sac,  it necessarily and unavoida-
bly carries with it  a proportional quan-
tity of the mesentery, which ew.ry body
knows   is  a strong  double membrane.
When the prolapsed:  part is at all consi-
derable,  this double membrane  is again
in  some measure  folded on  itself,  and
takes off a good deal of the effect of the
stricture on the intestine.  Now although
this  circumstance  will not prevent toe 
HERNIA.                                *l
effect, if the means of relief be totally
neglected, yet it will most  certainly  re-
tard the evil, and give more time  for
assistance; whereas, when there  is little
or none of the mesentery got through the
tendon, and the  thin, tender intestine
bears all the force of the stricture, it is im-
mediately brought into hazard.
  " The practical inference to be drawn
from hence, is too obvious  to need men-
tioning.
  " In the intestinal,  as  in tlie omental
hernia,  they which  have been often or
long down,  are in general more easily re-
turned, and do  not require such imme-
diate assistance, as they which have  sel-
dom  been  down, or  have  recently  de-
scended ;  and in the one kind of hernia,
as well as in the other, the state of  the
hernial sac, with  regard to size, thick-
ness, &c. depends very much on the date
of tlie  disease, and tlie regard  that  has
been paid to it.
   " If the hernia  be caused by a portion
of the intestine ileum only, it is in general
more easily reducible  than if a part of
the colon has descended with it,  which
will also require more  address and more
patience in  the  attempt.  The reductiou
of a  mere intestinal hernia too  (cxteris
paribus) will always remain more practi-
cable than tliat of a mere  omental one,
after it has  attained to a certain  size  and
state, as the part contained  within  the
former is liable to less alteration of form
than  that within the hitter; which altera-
tion has already been mentioned as no un-
 frequent hindrance of the return of an old
 caul rupture.
    ■« Not that the parts within a mere in-
 testinal hernia are absolutely exempt from
 such an alteration as may render their re-
 turn into  the belly  impracticable, even
 where  there is no stricture; for 1 have
 seen that  part of the mesentery, which
 has lain long in  the neck of the sac of an
 old  rupture, so  considerably hardened
 and thickened, as to prove an insuperable
 obstacle to its reduction.
   " Upon the whole, every thing consider-
 ed, I think it may be said, that an intesti-
 nal rupture is  subject to worse symp-
 toms,  and  a greater  degree of hazard,
 than  an  omental one, though  the latter
 is, by no means, so void of either as  it is
 commonly supposed to be; that bad symp-
 toms are more likely to attend  a recent
 rup ure than one of ancient date;  that
 the descent of a very small  piece of in-
 testine is more hazardous  than that  of a
 larger : that the hernia, which consists
 of gut only, is  in general, attended  with
 worse circumstances than that  which is
 made  up both of gut and caul;  and that
 no true judgment can be formed of any
rupture at all, unless every circumstance
relating to it  be taken  into  considera-
tion."  (Pott on Ruptures.)
  Mr. Hey coincides with Pott, in think-
ing  the prognosis more  unfavourable
when the tumour is small.  " I think it
is not a bad general rule,.that the smaller
tlie hernia, tlie less hope there  is of re-
ducing  it by the taxis.  Long-continued
efforts to reduce  a prolapsed intestine,
are most likely to succeed in  old and,
large hernias,  when no adhesions have
taken place."  (Pract.  Observ. in Surgery,
p. 203.)
  " The opening  (says Mr.  Lawrence)
through which the parts protrude, is nar-
rower in some  situations than in others ;
the progress of the case will therefore  be
more rapid* and the danger of the patient
more urgent.   The aperture is generally
very small  in  femoral hernia; this kind
of rupture in men,  and the bubonocele in
women, have  a particularly narrow en-
trance."  (Treatise on Hernia, p. 29.)
GENERAE OBSERVATIONS ON THE TREATMENT
              OF HERNIiB.

1. Treatment of those which are capable  of
  easy and immediate reduction and are not
  attended by any troublesome or bad symp-
  toms.

  " This case,"  says  Pott, " is very fre-
quently met with in infants, and some
times in adults, and is too often neglected
in both.   In the former, as the descent
seldom happens but when the  infant
strains to cry, and the gut is either easily
put up, or returns sud sponte, as soon  as
the child becomes quiet, it often is either
totally unattended to, or an attempt made
to restrain it only by a bandage made of
cloth, or dimity,, and which being inef-
fectual for  such purpose,  lays the foun-
dation for future trouble and mischief.
  •'This  is, in great measure, owing  to
a common opinion, that a  young infant
cannot wear a  steel truss : a generally
prevailing error, and which ought to  be
corrected. There is no age at which such
truss may not be worn, or ought not to be
applied ;  it  is, when well made, and pro-
perly put on, not only perfectly safe and
easy, but the only kind  of bandage that
can be depended upon :  and as a radical
cure  depends greatly on the thinness of
the hernial  sac^ and its  being capable of
being so compressed as possibly to unite,
and  thereby  entirely close  the passage
from the belly,  it must  therefore appear
to  every  one who will  give himself the
trouble of thinking on the subject, that
the   fewer  times the parts have made 
52                                HERi

a descent, and the smaller and  finer tlie
elongation  of the  peritoneum  is,  the
greater the probability of such cure must

  " The  same  method of acting  must,
for the same reasons,  be  good in every
age in which a radical cure  may reason-
ably be expected; that is, the prolapsed
parts  cannot be too soon returned,  nor
too carefully prevented from  falling down
again,  every, new  descent rendering  a
cure both  more distant and  more  un-
certain.
  " As soon as the parts are returned,
the truss should be immediately put on,
and worn without  remission, care being
taken,  especially if the patient  be  an
infant, to keep  the  parts on which it
presses constantly  washed,   to prevent
galling.
  " It  can  hardly  be  necessary to say,
that the surgeon should be careful  to see
that the truss fits,  as his success and re-
putation depend on such care.  A truss
which  does  not  press  enough,  is  worse
than none at all, as it occasions loss«of
time,   and  deceives the patient,  or his
friends; ;.nd one which presses too much,
or on an improper part, gives  pain and
trouble,  by producing  an inflammation
and swelling of the spermatic chord, and
sometines of the testicle.
  " In adults, whose ruptures are of long
standing,  and  accustomed  to  frequent
descent, the hernial sac is generally firm
and thick, and the aperture in the tendon
of the  abdominal muscle large; the free-
dom and ease with which the  parts re-
turn into  the belly, when the patient is
in a supine posture, and  the little pain
which  attends  a rupture of this kind,
often  render the persons who labour un-
der it  careless:  but all such should be
informed, that they are in constant dan-
ger of such alteration  in their complaint,
as may put them  into great hazard, and
perhaps destroy them.  The  passage from
the belly being open,  the quantity of in-
testine in the hernial sac is always liable
to be  increased, and  when  down, to be
bound by  a stricture.  An  inflammation
of that portion  ofthe gut  which is down,
or  such obstruction in it as may distend
and enlarge it, may at all times produce
such complaiuts as may put the  life of
the patient  into imminent danger;  and
therefore,  notwiihstanding this kind of
hernia may have been  borne for a great
length of time, without  having  proved
either  troublesome or hazardous,  yet as
it is alwajs possible to become so,  and
that very suddenly, it  can never be pru-
dent or safe to neglect  it.
  "Even though the  rupture should be
of the omental kind,  (which considered
abstractedly is  not subject to that de-
gree or kind of danger to which the intes-
tinal is liable) yet it may be secondarily,
or by accident, the cause of all the same
mischief;  for while it keeps the mouth  of
the hernial  sac  open,  it renders the de-
scent of a  piece of intestine always possi-
ble,  and  consequently  always likely  to
produce the mischief which may proceed
from thence.
  " They  who  labour  under a  hernia
thus circumstanced, that is,  whose  rup-
tures have been  generally down while
they have been in an erect posture, and
which have either gone up  of themselves,
or have been easily put up  in a  supine
one, should  be  particularly  careful  to
have their truss well made, and properly
fitted; for the mouth of the sac, and tlie
opening in the tendon  being  both large
and  lax,  and  the parts  having been
used to descend through them, if the pad
of the truss be  not  placed  right,  and
there be not a due degree of elasticity in
the spring,  a piece of  intestine will,  in
some posture, slip down behind it, and
render the truss productive of that  very
kind of mischief which it  ought to  pre-
vent.
  " It  is  scarcely credible  how very
small an opening will serve  for a portion
of gut or caul to  insinuate   themselves
into at  some times.   Now,  though  in
persons of mature age it most frequently
proves impracticable so to compress the
mouth of the hernial  sac, as absolutely
to close it, yet  by the constant use  of a
well-made truss, it may be  so lessened, as
to render  the descent of a  piece of intes-
tine into  it much more difficult: from
whence we  may learn  the great  conse-
quence of having the part  completely re-
duced before the truss is applied, and the
danger  that  may  be incurred by laying
such  bandage  aside  after it  has been
worn some  time; since the same  altera-
tion which renders the descent ofthe gut
less easy, will also make  the reduction
more difficult, if a piece should  happen
to  get down :  and hence  also we  may
learn why the bandage should be  long
and unremittingly  worn  by  all  those
whose time  of life makes the expecta-
tions of a perfect cure reasonable, many
of the ruptures  of adults being  owing
to  the negligent manner  in  which  chil-
dren at school are suffered to wear  their
trusses.
  " I know  a gentleman  who has  for
some  years  had an  omental  rupture,
which was neglected while  he was  young,
and he  haying naturally a  lax habit, and
the abdominal  opening  being much di-
lated, he  finds  it extremely  difficult  to
keep it up, even with the best truss  he 
HERNIA.                                53
can get, behind which it will sometimes
slip down: when tlus  happens, it gives
him such  immed ate and acute pain at
his stomach, and makes him  so intole-
rably sick, that he is obliged immediatelj
to. throw himself on his back, and pro-
cure the return of tlie piece of omentum."
(Pott or. Ruptures.)
   When we  have  considered the anatomy
of partcular herniae we shall  begetter
able to judge of  the proper construction
of trusses.  (See Truss.)

treatment of irreducible hernije, free
   from inflammation,  and unattended
   With troublesome, or dangerous symp-
   toms.

   " This incapacity of reduction may be
owing  to  several causes, .but  most fre-
quently arises either from the  largeness
of the quantity of the  contents, from an
alteration made in their form and texture,
or from connexions  and adhesions, which
they have contracted with each fther, or
with their containing bag.
   " I  have already  mentioned  it as my
opinion that ruptures are sometimes ren-
dered difficult to be reduceu, by that por-
tion ofthe intestinal canal which is called
the caecum, or the beginning of the colon,
being contained in  the hernial sac.  Of
which  tact ,1 am as much convinced as
the nature  of such kind of things will
permit;  that is, by observations  made
Both on the living and the dead.
   " When a hernia of this kind (viz, one
containing such a part of the intestinal
tube) has been long neglected, and suf-
fered to remain in the  scrotum without
any bandage  at all to support its weight,
the hernial sac being constantly dragged
down,  and  kept in  a state of distention,
necessarily   becomes  thick,  hard,  and
tough; by this means the diameter of its
neck is lessened, and  the  return  of the
intestine back from the scrotum into the
belly rendered more and more difficult, as
the parts through which it is to pass be-
come harder, and less capable of yielding.
This will, indeed, in time prove an ob-
struction sufficient  to hinder any part of
tlie intestine, or even  of the  omentum,
"from being  returned;  hut the more the
difficult)' is,  which proceeds  from the
mere figure  and size ofthe portion of gut,
the greater will be tlie obstruction when
added to that arising from the  just-men-
tioned cause.
   " An alteration produced by  time, and
constant, though gentle, pressure  in the
form  and consistence, or texture  of the
omentum, is also no infrequent cause, why
neglected omental ruptures become irre-
ducible.
  " The cellular membrane in all parts of
the body, however loose and light its na-
tural texture may be, is capable of becom-
ing hard, firm, and compact, by constant
pressure.  Of this there are so many, and
so well known instances, that it is quite
unnecessary  to produce any.
  " The  omentum, from its  texture, is
liable to the same consequence.   When a
portion of it has  been suffered to remain
for a great length of time in the scrotum,
without having  ever  been returned into
the belly, it often happens that although
that part of it which is in the lower part of
the hernial sac preserves its natural soft,
adipose, expansile state, yet all that part
which passes through  what is called the
neck  of the sac  is, by constant pressure,
formed into a hard, firm, incompressible,
carnous kind of  body,  incapable of being
expanded,  and  taking the form  of the
passage in which it is confined, exactly
filling that passage, and rendering it im-
possible to push  up the loose part  which
fills the scrotum.
   " This is no  theoretic  opinion,  but a
fact, which  I have seen and  proved oft-
en ; and  whoever will reflect on it, will
immediately find in it one  insuperable
objection to the return of some old omen-
tal ruptures.
   " The same reason for incapacity of
reduction is also sometimes met with in
ruptures of the  intestinal  kind, from  an
alteration produced  on that part  of the
mesentery which has been suffered  to lie
quiet for a  great length  of time  in the
neck of an old hernial sac.
   " The other impediment, which I men-
tioned, to the return of old ruptures, is the
connexion and adhesion ofthe parts, either
with each other, or with the bag contain-
ing them.   This is common to both the
intestinal and omental  hernia, and is pro-
duced by slight inflammations of the parts,
which have been permitted to lie long in
contact with each  other,  or pe^iaps in
many cases from the mere contact only.
These adhesions are more or less firm in
different cases, but even the slightest will
almost always be found an invincible  ob-
jection to tlie reduction of the adherent
parts, by the hand only.
   " Many, or perhaps most of these irre-
ducible ruptures become so by mere time
and neglect, and might at first  have been
returned; but when they are got into this
state, they are capable of no relief from
surgery but the application of a sQspen.
sory bag, to take off or lessen the*  incon-
  *  I am not unaware  (says Pott) that
most of these are capable of being cured
by the operation for the bubonocele, as it 
54
HERNIA.
venience arising from the weight of the
scrotum.
  "  People in  this situation should be
particularly careful not  to make any at.
tempts beyond their strength, nor aim at
feats of agility; they should take care to
suspend the loaded scrotum, and to keep
it  out ofthe way of all harm from pres-
sure,  bruise, &c.  When the tumour is
very large, a soft quilted bolster should
be worn at the bottom of the suspensory
to prevent excoriation, and the scrotum
should be  frequently washed for the same
reason;  a  loss of skin in this part, and
in such circumstances, being sometimes
of the utmost importance.  They ought
also  to  be particularly  attentive to  the
office of the intestinal canal, to see  that
they do not by  any irregularity of diet
disorder  it, and keep  themselves from
being costive, for reasons too obv ious to
need relating.  By these means, and with
these  cautions, many people have passed
their  lives for  many years free from dis-
ease,  or complaint,  with very large irre-
ducible ruptures.
  " On the other hand,  it is fit that man-
kind should be apprised, that the quiet,
inoffensive state  of this kind of hernia is
by no means to be depended upon;  many
things may happen to it, by which it may
be so altered, as to become hazardous,
and even  filial:  an inflammation of that
part of the gut  which  is  down, any ob-
steuction to the passage ofthe aliment or
feces through it, a stricture made by the
abdominal tendon, either on what has been
long down, or on  a new  portion which
may at any time be added to it, are always
capable  of so altering tlie state of the
case,  as to  put  tlie life of the patient
into danger.
  " Indeed  the  hazard arising  from  a
stricture made on  a piece of intestine
contained in the  sac of an old irreducible
hernia, is in one respect greater, than that
attending one that  has  been found at
times reducible; since from the nature of
is  called; but as I should never think of
proposing it in any case, in which there
are not symptoms, that threaten the life
of the pati-nt, so  I have not mentioned
it in this place as a means of cure.   I also
am not unapprised what influence a suc-
re-sful operation or two of this sort has
had on the unknowing; but I also know,
that  such accidental successes  have em-
boldened the same operators  to commit
more than one  or two murders, in  similar
cases; and that, from  the  prevalence of
fashion,  some  of  these rupture-doctors
have been largely  rewarded,  when  they
ought to have been hanged
the case it will hardly admit of any aj •
tempt  toward relief,  but the operation,
and that in these circumstances must ne-
cessarily be accompanied with additional
difficulty.
  " Among the ruptures which have been
thought not  reducible,  and treated as
such, there have been some  which, upon
more judicious and more patient attempts,
have been found capable of reduction.
  " When this is suspected to  be  the
case,  the  proper method is by absolute
rest, in a  supine posture, for a consider-
able length of time, by great abstinence,
and the use of evacuants, so  to lessen the
size of the parts in the hernial sac, as to
render them capable of passing back again
into the belly.''  (Pott on Ruptures.)
  Fabricius Hildanus  gives an account
of a man, who was radically cured of a
rupture, of twenty years'  date, by six
months' confinement to  bed.  (Cent. 5,
Obs. 54.)
  Le Dran and Arnaud relate instances of
monstrfcis bubonoceles, which disappear-
ed entirely, after the  patients  had been
long confined to bed, and become much
emaciated, by tedious illnesses.   Some of
the moderns have imitated this operation
of nature, and  by frequent  bleedings,
and repeated purges, have sometimes so
far  reduced the size of  the hernia, that
it has  been returned into the  abdomen.
Mr. Hey has several times succeeded in
this  way.   (P. 219.)   But,  this practice
cannot prove successful, when the viscera
adhere to  the  sac, or to  the peritoneum,
just within the abdomen.  The greatest
objection  to this method of cure, is the
want of an absolute criterion, by which
to distinguish, when the parts do, or do
not  adhere to the hernial  sac, and, in
advanced  years, though  one were sure,
that the viscera were  free from tlie sac,
the possibility of hurting  the body by
the necessary evacuations, is also another
objection.  (Sharp's Critical Enquiry, p.
15)
  Were the plan to be  thought worthy of
trial, keeping up a constant pressure on
the tumour, by means  of  a suspensory
bandage, made to lace  in front, would be
proper for promoting the absorption of
the  tliickened parts in  tlie  hernial sac.
Mr. A. Cooper has reduced  such herniae,
after applying ice to them, the good effects
of which  he imputes to  its producing  a
contraction of the scrotum, which per-
forms the office of a strong and permanent
compression of the tumour.
  Whenever any attempts  of this  kind
succeed, " a truss should be immediately
put  on, and worn  constantly without re-
mission ;  for,  in these people,  the large-
ness ofthe abdominal aperture, the thick- 
HERNIA.                               55
Hess of the hernial sac, and the relaxation
of the mesentery, make a new descent
always to be apprehended, and guarded
against."  (Pott.)
  There are instances,  however, on re-
cord,  in  which the  capacity of the ab-
domen had  become  so  adapted to the
diminished quantity of the viscera, that
when  the contents of the  hernia  were
reduced, serious  complaints  arose  from
their introduction into the belly. Schmuc-
ker has met with several such cases, in
which he has been obliged to  take off
the truss.  Petit  has known  the reduc-
tion of a hernia of this  kind  prove fatal,
the parts not descending again when the
truss was removed, the nausea and vomit-
ing, which  arose, continuing, and  peri-
tonitis taking place. (Chirurgische, Wahr-
nehmungen,  Vol.  2,  p. 243.  Traite" des
Maladies Chirurgicales, Tom. 2, p. 392.)
  Mr. Pott  remarks, that " an omental
rupture,  which has been so long in the
scrotum as to have become irredypible, is
very seldom attended with any bad symp-
toms, considered abstractedly;  but, it is
constantly capable of being the  occasion
Of an  intestinal hernia,  and all its conse-
quences ; neither is that  all, for the omen-
tum,  either  so altered in form and tex-
ture,  or so connected as to be incapable
of reduction,  may  by accident  inflame,
and either beoome gangrenous, or suppu-
rate,  and the  occasion of a great deal of
trouble." In a few instances, epiploceles
produce very bad symptoms indeed,  cases
of which are  to be found in Garengeot,
Dionis, &c.
  Sometimes,  in old cases of entero-epi-
plocele,  the  intestine is reducible, but
the omentum is not, in  which case  some •.
have  advised keeping up the piece of
bowel with a truss, the pad of which must
be  so contrived as riot to press on the
omentum.   Mr. Pott, however, contends,
that this is not often  practicable, and,
should such a truss be  used, he advises
its  being particularly attended to, lest a
small piece of gut slip down, and, being
pressed  on  by the truss,  produce fatal
mischief.
  " Irreducible herniae must of course be
exposed to all the consequences of exter-
nal injury  and violence; hence, various
cases are recorded, in which the bowels
have  been burst by blows, falls," &c.
(Lawrence on Hernia, p. 53.)

STMPTOMS AND TREATMENT OF  A STRAN-
  GULATED, OR  AN  INCARCERATED, HER-
  NIA.—MEANS TO  BE TRIED, BEFORE AN
   OPERATION.

  " Difficulty of reduction  (says  Pott)
may be owing to several causes.  The size
of the piece of omentum, or the inflamed
state of it; the quantity of intestine and
mesentery, an inflammation of tjie gut, or
its distention by feces, or wind; or the
smallness of  the aperture of the tendon,
through  which the hernia passes.   But,
to whatever cause it be owing, if the pro-
lapsed body  cannot be immediately re-
placed, and the patient suffers  pain, or is
prevented thereby from going  to stool, it
is called an incarcerated hernia, a stran-
gidated hernia, or a hernia with stricture.
  " The  symptoms are a swelling  in the
groin,  or scrotum, resisting the impres-
sion of the fingers: if the hernia be of
the intestinal kind, it is generally painful
to the touch,  and the pain is increased by
coughing, sneezing, or standing upright.
These  are the very first  symptoms, and,
if they are not relieved, are soon followed
by others,  viz. a sickness at the stomach,
a frequent retching, or inclination  to vo-
mit, a stoppage of all discharge per anum,
attended with a frequent, hard pulse, and
some degree  of fever."
  A patient,  thus  circumstanced,  is in
some danger, and demands immediate as-
sistance.   A  stricture made on  the pro-
lapsed part of the gut, by the aperture,
through which it passes, is the immediate
cause of all  the bad  symptoms; and of
course, the removal of such  stricture is
the only 'thing, which  can bring  relief.
This object can only be accomplished by
returning the bowel back into the abdo-
men,  or  dividing the parts, which form
the stricture.  The former  plan is  al-
ways  the  most desirable, when practi-
cable.
   We next proceed to notice  the various
measures to be adopted for the relief of a
strangulated  hernia, so as to  obtain tb<
best chance of doing away the necessily
of  an operation.  After treating of the
merits of each plan, a few remarks will
be  offered on  the  order  in  which the
means should be put in practice, a subject
that has  been most lamentably neglected,
even by the latest writers on this interest-
ing disease.
   Taxis.—This is the term applied to.the
operation of reducing a  hernia with the
hand.  It is much  promoted by the posi-
tion of  the  patient's  body; Winslow
thought it advantageous to have it placed
in an inclined plane/and  the thighs bent
towards  the  trunk.  Mr. A. Cooper ad-
vises the same practice,  observing,  that
this posture,  by relaxing the fascia ofthe
thigh,  relaxes  also the aperture, through
which the hernia passes.  Every degree
of tension, and relaxation of the femoral
fascia must undoubtedly  be at tended with
a corresponding change in the abdominal
ring.   But flexion  ofthe  thigh, besides' 
56
HERNIA.
relaxing this fascia, also relaxes the ab-
dominal, internal iliac, and psoas muscles.
The pressure,  which is  made on the tu-
mour by the hinds of the surgeon, should
always be directed upwards and outwards,
in  cases of  inguinal hernia,  along the
course ofthe sperm, it ic cord, and Mr. A.
Cooper advi-es it to be continued from a
quarter to  half an  hour. (On Inguinal
and Congenital Hernia.)
  As the  femoral  hernia passes down-
wards, and then  forwards, the pressure
must  be directed  first  backwards, and
then upwards.   No violence should ever
be used, for, besides being unavailing,  it
must greatly aggravate the inflamed state
of tlie contents of  the hernial sac, and,
it has even made the intestine  burst.—
(See Cooper on  Inguinal Hernia, &c p. 23.)
  Besides bending the thigh, care should
also be taken to rotate it inwards, which
will have great effect in  relaxing the  fe-
moral fascia, and  tendon of the external
oblique muscle.  Suspension of the pa-
tient over  the shoulders of an assistant
has been thought  to facilitate reduction:
"I  have tried  it often, (says Mr. Hey;)
but have not found it to be of such supe-
rior efficacy, as some authors have repre-
sented." (P.  144.)
  The return of a piece  of intestine is ge-
nerally preceded by a peculiar noise,  caus-
ed  by the passage of air through the! stric-
ture.  It recedes  at first gradually, and
then slips  up  suddenly.  The omentum
goes up slowly to the very last  portion,
which must be actually pushed  through
the  opening.  If  the taxis  should  not
succeed at  first, it will often do  so  after
the warm bath, bleeding, or cold applica-
tions.  Small herniae, being attended with
the closest  stricture, are the most difficult
to reduce,  and, for the same reason; cru-
ral  ones do not so often yield to the taxis,
as inguinal ones in the male subject. The
taxis becomes less likely to succeed, the
longer the  inflamed viscera have  been
down, because  adhesions are likely to
have formed.   Mr.  Liwrence  observes,
(p.  63 )  " When the rupture becomes
painful, we are no longer justified in per-
severing in attempts at reduction by the
hand.  A sufficient pressure cannot now
be endured; and the force which is em-
ployed only tends to increase the inflam-
mation, and accelerate  the  approach of
gangrene.  At this period, the operation  is
required, and should be performed without
delay?' Desault even proscribed the  taxis
altogether  in  the inflammatory strangu-
lation, until the  previous use of other
means had produced a change in the state
of  the swelling.  However, 1  should
never advise the reader to lose too much
tin^e in this way, on the supposition, that
he can  diminish the  inflammation  of a
strangulated  hernia  in any other  way,
than by delivering the bowels from the
pressure of the stricture.  Bleeding  may
check, but cannot  stop, much less dinu-
nish, the inflammation, that  prevails.
  That, however, the taxis  is  frequently
abused, and the cause of-serious mischief,
is  a truth, which cannot   be  doubted.
" Strangulated  herniae,  (says   Scarpa)
very frequently mortify from the negli-
gence of the patients,  and their repug-
nance to  submit  to  an operation,  and,
perhaps, still more  frequently from the
effect of the taxis, unskilfully exercised
by uninformed  surgeons, who are deter-
mined,  at  any price whatsoever, to ac-
complish the speedy reduction of the vis-
cera.  The majority  of them make  no
distinction between the acute,  and the
chronic strangulation.   In both cases,  no
sooner are the symptoms of strangulation
evinced, than they begin to handle the
swelling roughly, and to push the viscera
with all their  force,  in order to  make
them  return  into  the abdomen;  whilst,
when the strangulation is acute, and the
patient  young and strong, the taxis ought
never to  be  practised,  before  all the
means proper for diminishing the strength,
calming spasm, and relaxing parts, which
are to be reduced, have been employed
for a  certain time.  These  means, we
know, are bleedings,  fomentations, emol-
lient glysters, and, especially, the warm
bath,  which, next  to  bleeding, holds the
first rank.  At this school  of surgery, I
have frequently had opportunities of ob-
serving the salutary effect  of this  treat-
ment.   My pupils have, more than once,
seen  herniae,  which had been painfully
handled without any good, reduced, as it
were, spontaneously, after a bleeding,  or
whilst tlie patient was in  the bath.  If,
what  I have said upon the subject of the
acute strangulation, and  the  treatment
that it requires, were generally known  by
surgeons, I think, that the  operations  for
strangulated herniae would be  less fre-
quent.  Things  are   different, with re-
gard  to the  chronic strangulation of old
large herniae, in feeble, or aged persons;
for, in these  cases, it is of great import-
ance  to support tlie patient's strength.
Eleedings, the warm  bath,  and  other
weakening means, should also be avoid-
ed, which, in producing a general atony,
might bring on gangrene of the intestine,
either during tlie strangulation,  or  after
the reduction of the viscera.  It is ascer-
tained, that these  kinds of  strangulation
are almost always occasioned by an accu-
mulation of fecal matter, or an  extraor-
dinary quantity of air in the hernia.  No-
thing is more efficacious, than cold  appli- 
HERNIA.
57
   cations, for provoking the action of the
   bowel on the matter, which distends it, or
   for les^Ping the volume of the air.  They
   produce a corrugation of all the scrotum,
   and contractions of the cremaster, which
   alone sometimes suffice  for reducing the
   viscera, in a  much better manner, than
   could be done by the hands of the most
   experienced surgeon."  (Scarpa,  Traite"
   des Hernies, p. 244—247.)
     Bleeding.—The inflammation, which at-
   tacks the protruded viscera, and spreads
   thence over the whole abdomen, and the
   temporary weakness and  often fainting,
   which the sudden loss of blood induces,
   and which is a  peculiarly favourable op-
   portunity for reducing the hernia by the
   hand, are the reasons in  favour of bleed-
   ing in the present disease. Sharp,  Pott,
   B. Bell, Sabatier, Richter, Callisen, and
   Scarpa, names which can never be sur-
   passed in respectability, are all subscribed
   in favour of  bleaflftr. Wilmer, Alanson,
   and  A. Cooper flave published  against
   the practice.  Mr. Hey has related two
   cases, which strongly evince the manner,
   in which  bleeding  facilitates  the return
   of a hernia : the protruded viscera, in one
   instance, went up spontaneously, on blood
   being taken away;  in the other, the taxis
   succeeded immediately afterwards, though
   the  attempt  before  had  been made  in
   vain.   (P. 125, 126.)  Mr. Hey*s expe-
   rience, however, leads him to concur so
   far with Wilmer and Alanson^ as to de-
   clare, that bleeding  has  generally failed
 ■j to procure a reduction of the strangulated
   intestine, though he is persuaded that, in
   many cases, it "may be used with advan-
   tage.  But he cannot agree with Wilmer,
   that it  generally renders the subsequent
   operation more dangerous.  (P. 126 )—
   The majority  of candid practitioners, I
   believe, will allow,  that  bleeding is  al-
   ways proper, when  the  hernia is small
L   and recent; the abdomen tense and pain-
   ful ;  and  the patient young, strong, and
   plethoric.
     Purgative Medicines.—My  experience,
   (says Mr. Hey) leads me to condemn  al-
   most universally the use of  purgatives
   taken  by  the  mouth, while an intestine
   remains firmly strangulated.   In the en-
   tero-epiplocele, when the intestine has
   retired, and  the omentum remains stran-
   gulated ; or in a simple  strangulation of
   the omentum, where the intestine has not
   been prolapsed, purgatives are of great
   utility.  So  likewise  in very large and
   old  hernias,  where  there  is  reason to
   doubt, whether the disease  is not to be
   considered as a morbid  affection  of the
   intestinal canal, rather than the effect of
   strangulation, purgatives may be as use-
   ful  as in  the simple ileus without hernia.
        Vol. II.
While the intestine remains firmly stran-
gulated, they usually increase the vomit-
ing, and add to the distress ofthe patient.
If they are to be tried at any time with
hope of success, the trial would appear to
have the greatest advantage when the vo-
miting has been removed by means of an
opiate; yet I have repeatedly given  them
in vain during such  an  interval  of relief."
(Practical Observations in Surgery, p. 128.)
  Purgatives are supposed to operate by
exciting the peristaltic action ofthe intes-
tine, and thereby extricating it  from the
stricture.  Besides the above eminent sur-
geon, Pott and Richter have  joined in
their condemnation in general, and,  to all
appearances,   with  very   great  reason.
Purgative glysters, certainly have not the
objection of increasing the irritation; but,
their  efficacy  is not  deserving of much
confidence.  Mr. Hey  says, he  has never
seen one case, in which either purgative,
or emollient glysters produced a return of
a strangulated hernia.  Such  injections
will empty the large intestines;  but, they
have seemed to him to do no more.  It is
common also for a natural evacuation to
be the immediate consequence of a stran-
gulation.  (P. 131.)
  Warm  Bath.—" Many instances  (says
Hey) are upon record of the good effect
of warm bathing in procuring the reduc-
tion of a strangulated  hernia.   I have of-
ten seen it useful;  but I have  also often
seen it fail of success.  Whenever it is
used in  this disease, the  patient should
be placed, if possible, in a horizontal  po-
sition.   Gentle efforts  with the hand to
reduce the prolapsed part are perhaps at-
tended with less danger, and with greater
prospect of success, while the patient lies
in the bath, than in any  other position.
The  free  use  of opiates coincides  with
that  of warm bathing,  and under  somet
circumstances, these means deserve  to be
tried  in conjunction."   (P. 132.)
  Cold Bath, and Cold Applications.—The
cold bath, and dashing of cold  water on
the patient are little to be depended upon,
though success seems sometimes to have
been obtained in this manner. (Petit Traite-
des Mai Chir. Tom. 2, p. 325. Hey, p.  136.)
  Wilmer has strongly recommended the
application of cold to the tumour itself,
and this plan has acquired  the approba-
tion of the most celebrated modern sur-
geons.  It is  generally tried in conjunc-
tion with  the  effect of tobacco glysters,
which  will be presently noticed.   Cold
applications, in the form of ice,  were, in-
deed,  particularly  recommended  by B.
Bell.  The best way is to pound tlie ice,
tie it up in a bladder, and place it on the
rupture.  When ice cannot be procured,
Mr. A. Cooper employs a mixture of equal
  H 
58
HERNIA.
parts of nitre and sal-ammonfac.  To one
pint of water, in a bladder, ten ounces of
the mixed salts  are to  be added.  " If,
after four hours,  (says this distinguished
surgeon) the symptoms become mitigated,
and the tumour lessens, this remedy may
be  persevered in, for some time longer;
but, if they continue with unabated vio-
lence, and the tumour resist every attempt
at  reduction, no  farther trial should  be
made of the application."  (On Inguinal
and Congenital Hernia.)  When  ice  has
not been at hand, aether has occasionally
been found a good  substitute, when  al-
lowed to evaporate from the surface of the
swelling.
  Care must be  taken, that the  cold be
not so applied as  to freeze the scrotum,
and bring  on sloughing.  (A.   Cooper,
p. 15.)
   Opiates.—Mr.  Hey has  seen  several
cases, in which opiates, given freely,  (in
athletic persons after bleeding) have pro-
cured a reduction of strangulated liernia.
  He cannot say,  however, that this  re-
medy is generally successful; but, it has
the advantage of removing, for a time,
the pain and vomiting usually attendant
on  strangulation, even  though  it prove
ultimately inefficacious.  Opiates should
be  given in large doses, when it is wished
to try their effect in procuring reduction ;
and whenever the symptoms of strangula-
tion return, after having been removed
by  opiates, the operation should be per-
formed without delay.  (P. 134, 135.)
   Tobacco Glysters.—For this purpose,
some surgeons prefer a decoction of to-
bacco, made by  infusing, or boding, one
dram of the plant, for ten minutes, in  a
pint of water; others employ the smoke,
which is  prepared,  and introduced into
the rectum, by means of a  well-known
apparatus   for  the  purpose. Perhaps,
both methods are equally efficacious ; but,
as  one  requires an apparatus, while  the
otlier does not, and is equally proper,  the
decoction may be entitled to most recom-
mendation.  The machine for the smoke
is  also  frequently found  out of  order.
Tobacco glysters are, next to the opera-
tion, the most certain means of bringing
about the reduction of the strangulated
parts.  They not  only excite the action
of the intestines, they also exert a pecu-
liar depressing  influence  on the whple
 system, reducing the pulse, and  causing
 nausea and sickness, cold  sweats and
 fainting, under which circumstances the
 parts  recede spontaneously,  or  may be
 easily  reduced.   Mr.  A.  Cooper pru-
 dently  advises injecting  half the above
 quantity at first; for he has  seen two
 drams, and  even one,  when  used as an
infusion,  and introduced at once, prove
fatal.   (P- 24)   The  rest  should pre-
sently be injected when it  appears, that
the tobacco does not operate wiljpfhe ex-
traordinary v.olence, with whiclfit does
in a few particular constitutions.
   Poultices  and Fomentations.  We only
mike ment.on of these, to say, they have
not the least confidence of any experienc-
ed, or  intelligent  surgeon.   Whoever
wastes time, in these urgent cases, in try-
ing the effects of such applications, merits
censure for his credulity,  ignorance, and
unfitness to undertake the treatment of a
rapid disease, in which, as Pott remarks,
if we do not get forward, we generally go
backward ; and whatever does no good,
if it be at all depended upon, certainly
does harm, by occasioning an irretrievable
loss of time.
   [Placing the patient on an inclined plane,
with   his  feet   highest.— Winslow  and
Cooper recommended this position of tlie
body  during  the eftbj^«.to reduce the
hernia by taxis.   I  wotft recommend it
however,  to  be  continued longer; from
having seen two cases in  which  this
simple  measure  succeeded  after seve-
ral of those,  already recited,  had been
tried  in  vain.  The  patient  should lie
upon his back, and the foot of the bed
be elevated about  twenty  inches higher
than the  head.   This posture  need not
interrupt  the administration  of  other
remedies, and  in  some  cases  will  be
found powerfully to aid them.]

OF THE ORDER,   IN WHICH  THE  PRECED-
   ING METHODS   AND  REMEDIES  SHOULD
   BE  TRIED,  AND  OF  THE TIME,  WHEN
   THE  OPERATION  SHOULD  NOT  BE  DE-
   LATED.

   In the treatment of a strangulated her-
nia,  a surgeon cannot be too deeply  im-
pressed with the danger of spending tin. -
in the trial of methods of inferior efficacy,
or of such as are evinced to be ineffectual
in the cases before  them.
   The rapidity,  with which gangrenous
mischief sometimes arises, and the patient
loses his life, has been  proved  in a mul-
titude of unfortunate examples, and should
operate as a  warning  to all practitioners
against the  danger of deferring the ope-
ration too  long.  In  the course of my
reading, however, I have not met  with so
remarkable an  instance  of the  sudden
mortification, and  rapidly fatal termina-
tion of an hernia, as the following case re-
corded by Mr. Larrey, in speaking of the
fatiguing and forced  marches  performed
by the French soldiers  in Egypt.   These
marches, he says,  brought on in one of
the mditary " a hernia which formed sud-'
 denly, and became  at the same time str. a- 
HERNIA.
&
gulated.  He  was  immediately brought
to my ambula-ice; but,  a spontaneous
gangrene, which had all on a sudden at-
tacked the  intestine, and extended to the
other abdominal viscera, caused the pa-
tient's death in the space of two hours,
and made it impossible for me to do the
operation for him.  This is  the second
example, that I  have been  acquainted
with, in which the effects of the accident
were thus rapid."   (Larrey, in Me'moires
de Cfururgie Milttaire, Tom. l,p. 196.)
  The taxis is generally among  the  first
things to be  tried, and  Mr. A. Cooper
thinks the attempts should be continued
for a quarter, or half an hour.  When
these have  been ineffectual, the patient,
if the circumstances do not forbid, should
be  immediately  bled, and have a large
opening  made  in  the vein, so  that the
suddenness of the evacuation may be most
likely to  bring  on fainting.   The  taxis
should be tried once more as soon as this
operation is finished.
  In  cases, where the strangulation  is
very  acute, and the patient  young and
strong, perhaps, it may be most advisable
to follow the advice delivered by Scarpa
and Desault, and bleed the patient,.and
put him in the warm bath, before attempt-
ing the taxis.
  If bleeding alone lfas been  practised,
and the manual efforts at reduction should
not now succeed, the warm bath may be
employed, provided it can begot ready in a
very short time, but none should  ever be
lost in  waiting  for it  to  be  prepared.
When the bath is used, the taxis may be
attempted, as the patient lies in  the wa-
ter; a  situation, in  which I  have suc-
ceeded  myself in reducing several her-
niae.
  Certainly not  more   than  one  hour
should ever be  allotted for putting  in
practice  the first attempts at reduction,
bJMding, and the warm bath.
 ™he plan should  be, while the trial of
one thing is going on, another should be
preparing.  So when the preceding  mea-
sure* have been  tried in vain,  the appli-
cation of a bladder filled with ice, or the
solution of salts, and the injection of to-
bacco, m the form of smoke, or decoction,
should never  be  delayed for want of due
previous preparation of all tlie requisites.
Both these measures should be  practised
at the same time,  immediately  after the
failure of the taxis,  bleeding,  and  the
warm bath.  Mr. A.  Cooper states, that
four hourfc  are enough for the trial of the
tobacco glyster, together with cold  appli-
cations.
   In  omental1 herniae, the necessity for
operating may frequently be obviated, by
the  good effects of  bleeding, purgative
medicines, and glysters, and leeches ap-
plied to the tumour. ' Mr. Lawrence had
justly observed, that " when, as it very
frequently happens, the aid of the surgeon
is not required, until the complaint has
lasted for some time, a trial of the tobac-
co, together with the topical use of cold,
should be immediately resorted to, as cir-
cumstances will not admit of delay in the
previous use of less powerful remedies."
(P. 87.)
   Every man who has seen much of her-
niae, will immediately recognize the pro-
priety of the following, sentiments of the
experienced Mr.  Hey:
   " I can scarcely press  in too  strong
terms the  necessity of an early recourse
to the  operation, as the most effectual
method of preserving life.in this danger-
ous disease. ' If  Mr. Pott's opinion be
true, that the operation, when perforrtied
in a proper manner, and  in due  time,
does not prove the  cause of death oftener
than perhaps once in fifty times; it would
undoubtedly preserve the lives  of many,
to perform it almost as soon as the disease
commenced, without increasing the dan-
ger by spending much time in the use of
means, which cannot be depended upon
for a cure.
   " I have twice seen this disease  prove
fatal in about twenty-four hours. In such
cases it  is evident there is little time for
delay.  A surgeon, who  is competent to
perform  the operation,   is  not perhaps
consulted till the intestiie is on the point
of being mortified, or is actually in a state
of  mortification.  The   dilemma  into
which he is then cast, is  painful indeed.
But  when  the fullest opportunity is af-
forded him of using the  best  mode  of
treatment, I am satisfied that his success
will be the greatest when the  operation
is not  long delayed.  This, at least,  has
been my own experience.   When I first
entered upon the profession of surgery, in
the year 1759,  the operation for the stran-
gulated hernia  had  not been performed by
any ofthe surgeons in Leeds.  My seniors
in the profession were very kind in af-
fording me their  assistance, or calling me
into consultation  when such cases occur-
red ; but we considered the  operation as
the last  resource, and as improper until
the danger appeared imminent.  By this
dilatory mode  of practice, 1 lost three pa-
tients in five  upon whom  the  operation
was performed.  Having more experience
of the urgency of  the disease, 1 made  it
my custom, when called to a patient who
had laboured two or three days under the
disease,  to wait only about two  hours,
that I might try the effect of bleeding (if
this evacuation was not forbidden by some
peculiar  circumstances of the case)  and
the tobacco glyster.  In this mode   of
practice  I lost about two patients in nine 
60
HERNIA.
upon  whom I operated.  This compari-
son is drawn from  cases  nearly similar,
leaving out of the account  those cases in
which a gangrene  of the intestine  had
taken place.
  " I have now,  at the time  of writing
this, performed the operation thirty-five
times; and have often had occasion to
lament that I had performed it too late,
but never  that  I had performed  it too
soon.   There are some cases  so urgent,
that it is not advisable to lose any time
ip the trial of means to produce a reduc-
tion.  The delay of a few  hours may cut
off all hope  of success, when a speedy
operation migrht have saved the life of the
patient."  (P. 141, &c.)
  To determine the exact  moment, when
to give up the trial of the  preceding mea-
sures, and to have  immediate recourse
to the operation, is certainly  difficult;
but,  no one can doubt, that this should
rather be  resorted to too  early, than too
late.
  All directions must be general ones,
liable to many r-xceptions :  in rapid cases
little, or no time should be allotted to the
trial of any plan, and tlie operation should
be done without th^ least delay   In other
instances,  we have full time to try tlie ef-
fects  of every thing at all likely to  suc-
ceed.   The symptoms, which  ought to
guide us, in having recourse to the  ope-
ration, arise from an attack of inflamma-
tion in that part ofthe  intestine contained
in the hernial sac, and from its spreading
into the abdominal cavity.  It is in  pro-
portion to their violence,  that we  ought
to urge the performance of the operation.
Mr.  A. Cooper considers  pain on  press-
ing the belly, and tension, as the symp-
toms, which point out its  immediate ne-
cessity.  He adds,  :* Indeed, there  is
scarcely  any period  of  the  symptoms,
which should forbid the  operation;  for,
even  if mortification has  actually begun,
the operation may be the means of saving
life,  by promoting  the ready separation
of gangrenous parts."  (On Inguinal and
Congenital Hernia, p. 27.)
  Whenever the  surgeon has succeeded
in reducing the parts, without having re-
course to the knife, if the  symptoms  of
pain,  inflammation, &c. ran high  before
such  reduction, "they will not always cease
immediately afterwards.   As they  proba-
bly depend on the reduced bowel having
been  inflamed by the stricture, the body
should be kept open, and  tlie diet and re-
gimen should be low and sparing, while
the least degree  of pain  and  tension re-
main; in short,  till all complaint is ab-
solutely removed from the abdomen, and
the  intestines do their office freely  and
without trouble.  (Potf.)         ''
PROGRESS OF THE SYMPTOMS  OF A ST1AN-
           DULATED HERNIA.
  The earliest  symptoms have  been al-
ready related, viz. " tumour in the groin,
or scrotum,  attended with pain, not  only
in the part, but all over the belly, and
creating  a sickness and inclination to vo-
mit, suppression of stools, and some de-
gree of fever.   These are the first symp-
toms, and, if they are not appeased by the
return of the intestine, that is, if the at-
tempts, made  for this  purpose, do  not
succeed; the sickness becomes more trou-
blesome, the vomiting more  frequent, the
pain more  intense,  the tension of  the
belly greater, the fever higher, and a ge-
neral restlessness come on, which is very
terrible to bear. When this is the state of
the patient, no  time  is to be lost; a  very
little delay is now of the utmost conse-
quence,  and if the one single  remedy
which  the disease is now capable of be
not administered immediately,  it will ge-
nerally baffle every other attempt.  This
remedy is the operation, whereby the part*
engaged in the  stricture may be set free.
If this be not now performed, the vomit-
ing is soon  exchanged for  a convulsive
hiccough, and  a  frequent gulping up of
bilious matter; the  tension  of the belly,
the  restlessness  and fever  having been
considerably increased for  a  few hours,
the  patient  suddenly becomes  perfectly
easy, the belly subsides, the  pulse from
having been hard, full, and frequent, be-
comes low, languid, and generally inter-
rupted ; and the skin, especially that of
the limbs, cold and moist; the eyes  have
now a langour and a glassiness, a lack-
lustre  not easy to be described; the tu-
mour of the part disappears,  and the skin
covering it, sometimes changes its natural
colour for a livid hue ; but whether it
keeps or loses its colour, it has an emphy-
sematous  feel,  a crepitus to the touch,
which will easily be conceived by all Jfco
have attended  to it, but is not so easySjto
convey an idea of by words: this crepitus
is the too sure  indicator of gangrenous
mischief within.  In this state,  the  gut
either goes up spontaneously,  or is re-
turned with the  smallest degree of  pres-
sure ;  a discharge is made by  stool,  and
the patient is generally  much  pleased at
the  ease he finds; but this pleasure is of
short duration,  for the hiccough and the
cold  sweats  continuing and increasing,
with the addition of spasmodic rigors and
subsultus tendinum, the  tragedy  soon
finishes."  (Pott)

ANATOMY OF;THE BUBONOCELE, OR INGUI-
              NAL HERNIA.

   This subject must necessarily precede 
                                   HERNIA.                                61

tlie account ofthe operation, which would  ated by Albinus; Gimbernat makes dis-
otherwise be unintelligible.   It is chiefly  tinct mention of it in his Account of a new
in the anatomical information, relative to  Method ofOperating for Femoral Hernia, p.
herniae, and the mode of operating, that  19—32; but, no one, before Mr. A. Coo-
modern surgeons have  a decided  supe-  per, considered the thing with due at-
rioxity over their predecessors; for, be-  tentien.
fore Gimbernat, Camper, Hey,  and A.    The  abdominal ring is then only the
Cooper, published their several works on  outer opening of the  canal,  or passage,
herniae, the anatomy  of the disease was  through which the spermatic cord passes
only imperfectly understood.              before it emerges. The inner one, at which
  The tendinous fibres of the aponeurosis  the viscera in cases of inguinal hernia first
of the external  oblique muscle, as they  protrude, is situated about an inch and a
run downwards and forwards towards the  half from the abdominal ring, in the di-
pubes, separate from each other, so as to  rection  towards the  anterior spinous pro-
leave a  triangular  opening,  called the  cess ofthe ilium.  This inner opening is
abdominal ling.  The upper and  inner  rather nearer the  pubes, than the ilium,
pillar (as it is termed) of this aperture is  and its upper border is formed by the low-
inserted into the symphysis of the pubes;  er edge ofthe internal, oblique, and trans-
the lower and  outer  one, which is only  verse muscles, which  can be plainly felt
the continuation of Poupart's ligament,  with the  finger, introduced upward and
is fixed into the angle and  crista  of the  outward into the abdominal ring.
same bone.  Some  tendinous fibres cross    " The precise point, at which the her-
the upper and outer angle of the ring, so  nia most commonly  commences,  (says
as to diminish the  triangular appearance  Scarpa) is that which corresponds, in the
of the whole aperture: these are said to  foetus, to the communication of the tunica
be very strong in  old  herniae.  The an-  vaginalis with the peritoneum, and, in the
terior and thicker layer ofthe aponeurosis  adult, to the passage ofthe spermatic cord
of  the internal  oblique muscle joins the  under the transverse muscle. In the sound
tendon of the external oblique; the pos-  state, the peritoneum presents at this part
terior  and thinner  one joins  that of the  a small funnel-like depression, the depth
transversalis;  but  the  lower portion  of of  which increases  in proportion as the
this tendon, together with the correspond-  spermatic cord is pulled from above down-
ing part of the transversalis, goes wholly  wards.   It is this small pouch, this sort
in front of the  rectus muscle.  Thus the  of  digital appendage, whose progressive
inferior border of  the  obliquus internus  developement constitutes the hernial sac.
and transversalis, which originates from  Resting upon the anterior surface of the
the upper part of Poupart's ligament, lies  spermatic cord, it first makes  its appear-
behind the outer pillar of the abdominal  ance under the inferior edge of the trans-
ring.  Mr. A. Cooper, was the first, who  verse muscle; thence  it extends itself in
noticed, that a thin fascia proceeded from  the separation of the inferior fleshy fibres
the inner edge of Poupart's ligament, and  ofthe internal oblique muscle, always fol-
spread itself over  the  posterior surface  lowing  the spermatic cord,  in front  of
of the transversalis.  This forms the only  which  it is situated;  and after having in
partition between the peritoneum and the  this manner passed through the  whole of
outer opening of the abdominal ring, and  the canal, which  extends from the  iliac
were it not for its existence, inguinal her-  region  to the pubes, it lastly protrudes at
niae would probably  be much more fire-  its external orifice, which is the inguinal
quent.                                   (or abdominal) ring properly so  called.
   The  spermatic vessels joined by the  In  all this track, the hernial sac, as well
vas deferens, proceed before  the epigas-  as  the  spermatic cord, is situated above
trie artery, very near the place where it  the femoral arcli, the direction of which it
arises.  They then run through the above  follows.  The canal,  which it traverses,
fascia, go under the  edge of the internal  is of a conical shape, the apex of which is
oblique and transverse muscles,  and next  towards the flank,  and the base at the
obliquely downwards and  forwards  be-  external orifice of the ring."  (Scarpa,
tween the above fascia, and  aponeurosis   Trait6  des Hernies, p. 44, 45.)
of the  external oblique to  the opening     The  epigastric artery runs behind the
ofthe ring.                             spermatic cord, along tlie inner margin
   Thus  we see, that the spermatic cord  ofthe internal opening ofthe above canal,
runs through a kind of canal,  before it  \hen upwards and inwards,  so as to  pass
actually emerges at  what is named the   at  the distance of half an inch, or an inch
abdominal ring.  This oblique passage of from the upper extremity  of the  outer
the cord, through the abdominal parietes,  opening, or abdominal ring.
was well known to, and elegantly deline-    In common  cases of inguinal hernia, 
82                                  HERNIA.
the viscera, protruded at  the inner open-
ing, above  described, lie over the sper-
matic cord, and form a tumour on the out-
side of the  abdominal ring.  They may,
however, insinuate themselves into the
inner  opening, without descending suffi-
ciently to protrude through tlie external
one, or abdominal ring.  The stricture
may take place at either of these open-
ings.  In recent and small hernia, accord-
ing to Mr.  A. Cooper, the  strangulation
is  most frequently situated at the inner
opening;  in large old rupture*, at the
abdominal ring.  Even when the parts are
completely protruded out  of  the latter
opening, the strangulation  may exist at
the inner one: but, there may occasionally
be  two strictures, viz. one at each open-
ing.  (Lawrence on Hernia, p. 103.)
  The hernial sac descends through the
abdominal ring over the  spermatic cord,
and is covered by a fascia,  sent off from
the tendon of the external oblique mus-
cle.  Beneath this fascia, the  cremaster
muscle is also situated  over  the sac.
When this has descended a certain way,
it lies on the tunica vaginalis, as well as
the spermatic cord.
  As  the epigastric artery naturally runs
first behind the spermatic cord, and then
along  the  inner margin  of the internal
opening of  the ring,  and as the  viscera
are protruded over the cord,  they must
be situated on the outer side of the artery,
which runs  first behind  the neck of the
sac, and then on its inner  side.   Hence,
the inner margin of the sac, when  in-
spected on the side towards the abdomen,
seems to be formed, as  it were, by the
track of the vessel.  (See  Lawrence, p.
106.)   That this is the ordinary situation
of the epigastric artery, in relation to the
inguinal hernia, is confirmed by the con-
current testimonies of Camper, Chopart,
Desault^Sabatier,  A. Cooper, &c. and by
preparations to be seen  in almost every
museum.
   In recent inguinal herniae, the internal
and external openings of the ring are at
some distance from each other, tlie first
being situated obliquely upwards and out-
wards in relation to the former; but, tbe
pressure of the protruded viscera, gradu-
ally brings them nearer together, so that
in large herniae of long standing, the open-
ing into the  abdomen is almost direct,
and the epigastric artery becomes situated
nearer the pubes, than in the natural state.
   Though such is the ordinary direction,
in  which a bubonocele protrudes,  there
are occasional varieties.  In one of these,
the viscera, instead of descending through
the canal of the ring, are at once thrust
through the abdominal  ring  itself, and
the opening into the belly is then direct:
the hernial sac, instead of passing on tlie
external side of tlie spermatic vessels, as
is usual,  now lies on their inner, or pubic
side;  and the  epigastric artery, which is
commonly situated behind, now pursues
its course, in front of the sac, at its usual
distance from  the upper and outer angle
of the abdominal ring.
  The following is Scarpa's description of
the displacement of the epigastric artery
in the greater number of cases of inguinal
hernia. " This artery, which, in the natu-
ral state, runs about ten lines from the
abdominal ring, has its situation and direc-
tion so changed, in subjects a^-cted with
hernia, that it crosses the  posterior part
of the neck of the hernial  sac, and is
pushed from the  outer  to  the inner side
of the abdominal ring.  In order to com-
prehend the reason of this displacement,
it is necessary to recollect what I have
elsewhere said of the formation of inguinal
hernia, and  of the manner, in which  the
spermatic cord crosses  the epigastric ar-
tery.   The hernia begins to form at  the
very  place, where  the  spermatic  cord
passes under  tlie inferior margin of  the
transverse muscle; and this place is ra-
ther nearer the flank, than that where the
epigastric artery  passes towards the rec-
tus muscle.   In its  progressive develope-
ment,  the hernial sac constantly follows
the same track as  the spermatic  cord,
since it is situated upon its anterior sur-
face.  As has been already explained, this
cord crosses the epigastric artery ; conse-
quently, the hernial sac must necessarily
pass with the cord above this artery, be-
fore protruding  from  the  canal of the
abdominal ring.  At the same time, the
internal  orifice of the hernia becoming
larger, and the inguinal canal shortened
by the approximation of its two orifices to
each other,  it follows, that, at the period,
when  the hernia begins to make its ap-
pearance in  the  groin,  the  epigastric
artery is unavoidably situated behind the
neck  of the  hernial sac, and is pushed
from the outer to the  inner side of the
ring.  Let us suppose a piece of string to
be passed from the inside ofthe abdomen
into the scrotum, all through tlie inguinal
canal, and the middle of the hernia;  and
that  this string  is pulled so as to bring
the internal orifice ofthe hernia,  which is
situated beyond the point where the sper-
 maUc cord  crosses tlie  epigastric artery;
 this artery will immediately be found to
 be earned from the outer to the inner side
 of the neck of the hernial sac.  The same
 thing happens from the effect of the de-
 velopement of the hernia.  The removal
 of" the epigastric artery from one side of
 the ring to the other  (says Scarpa)  is a
 phenomenon, which may be regarded  a.' 
HERNIA.
63
almost constant in the inguinal hernia.  I
have examined the bodies of a great num-
ber of subjects, affected with this species
of hernia; and  it has  been only in a very
few, that I met with the epigastric artery
retaining its natural situation on the outer
side of  the  abdominal ring.  In  investi-
gating the reason of this exception, 1 have
observed, in all the individuals who pre-
sented it, a very  remarkable  weakness
and flaccidity of that part of the abdomi-
nal parietes, which extends from tlie flank
to the pubes. In all the displaced viscera
had passed  through the aponeuroses of
the transverse and internal oblique mus-
cles, not in the  vicinity of the ilium, as is
commonly the case, but, at a little  dis-
tance from the pubes, giving to the upper
pillar of the ring a  curvature that is
extraordinary, and dispropprtioned to the
smallness of the hernia.  I observed, also,
that the neck of the hernial sac did not
pass in an oblique direction from the flank
to the pubes, but, that it protruded from
the abdomen almost in a direct  line from
behind forwards.  In  short, in  these  in-
dividuals, the small cul-de-sac ofthe peri-
toneum, which constitutes the origin of
the'  hernial  sac,  had  not  begun  to  be
formed  under the edge of the transverse
muscle,  at the point where the spermatic
cord  runs outward; but, it  had passed
through the aponeuroses of the internal
oblique  and transverse  muscles, at a
little distance from the pubes, and within
the point, at which the  spermatic cord
crosses  the epigastric artery.   The small
hernial  sac,  having at this  part come
into contact with and united  to the sper-
matic cord, protrudes at the external ori-
fice  of  the  inguinal canal, without  dis-
placing  the  epigastric artery  from  its
natural situation.
  " This species of hernia, properly speak-
ing, is a mixture of the ventral and inguij
nal.  It  resembles  the former,  inasmuch
as the hernial sac. pierces the aponeuroses
of the  transverse  and internal oblique
muscles; the latter, inasmuch as it passes
out at the abdominal ring, conjointly with
the spermatic cord."  (Scarpa, Tndl6 des
Hernies, p.  68, tyc.)  In most  instances,
the spermatic cord  lies behind or under
the hernial sac.  There are cases, however,
iu which the vas deferens is found on  the
outer side of the  sac, while the  rest of
the spermatic cord lies, as it usually does,
on the inner side, or rather under this
part (Cooper.)  Le Dran, Schmucker, and
Blizard, have found the whole cord situ-
ated in  front of the sac.  Sometimes  the
vas deferens has run on the front and in-
ner part, and the rest of the cord on  the
back and external part of the swelling.
(Camper, Hm.)  The cord has been known
to be before, and the vas deferens behind
the sac.  (Camper, Cooper.)
   Upon this part ofthe subject, the reader
may deem the following passage interest.
ing. " While the hernia is of moderate
size (say9 Scarpa) the surrounding cellu-
lar substance  is  not very greatly  com-
pressed, and no change is observed in the
situation of the spermatic vessels.  The
artery and veins of this name always form,
with the vas  deferens, one single cord,
which is intimately adherent to the pos-
terior surface ofthe hernial sac.  But, in
proportion as the tumour increases in size,
the cellular substance, which immediately
surrounds it and unites it to the spermatic
cord, is more and more  distended  and
compressed.  At  length, at a certain pe-
riod, the distention is carried to such a
pitch, that the spermatic vessels are sepa-
rated from one another, and change their
position with respect to the hernial sac.
This kind of gradual decomposition of the
spermatic cord is quite similar to that,
which would be produced by pulling tlic-
surrounding  cellular substance  in  two
opposite directions.  Such is the reason,
why, in scrotal hernix of large  size, the
spermatic artery,  the vas  deferens,  and
the  spermatic veins are  found  separated
upon the posterior surface of the sac.  All
these vessels, instead of being  conjoined
in one cord, are  divided by interspaces.
which  are  sometimes very considerable.
Ordinarily, the vas deferens is  less sepa-
rated from the spermatic artery, than from
tlie vein of this name.   In some subjects,
Camper has seen it situated on one side of
the sac, and the  artery and veins on the
other.   (Icones Herniamm, tab.  5. L.  O.
Tab. 8. 1, 2 )  The displacement and de-
composition of the spermatic cord take
place equally in adults and in children af-
fected with large scrotal herniae.  (Camper,
loco cit.) In general, towards the upper
part and neck of the hernia, the vessels are
not much separated; but, as they proceed
downwards, they diverge more and more.
Sometimes, when the hernia is very old
and voluminous, they are no longer found
at the posterior part, but rather at the
sides, and even on the front surface of the
sac; they shew themselves through the
cremaster muscle, which covers them, and
form a sort of vascular train, which arrests
the hand of the operator at the moment,
when he is about to open the hernial sac.
Le Dran relates, that, m operating upon a
large scrotal hernia, he found the sper-
matic cord on the anterior surface of the
hernial sac.  (Operations de Chir. p. 127.)
This fact has been the cause of numerous
conjectures, and appeared altogether in-
conceivable to such surgeons, as have not
been acquainted  with  the changes,  to 
64                                HERNIA.
% which the spermatic cord is exposed,  in
 cases of large  scrotal herniae.   (Lassus,
 Med Operat. Tom. 1, p.  152, cannot con-
 ceive th\- possibility of the occurrence.)
 The observation of Le Dran is not the
 les.. true and exact: it exemplifies a very
 import ant fact, of which it is easy to give
 a true explanation, when the state of the
 spermatic cord in ordinary inguinal her-
 niae, and in those, which have obtained a
 considerable size, has been comparatively
 examined. In the first, the spermatic cord
 quite entire is always found situated on
 the posterior surface of the hernial sac ;
 but, in the second, the spermatic vessels
 are so separated  from one another, that
 they sometimes extend over the sides and
 even  the forepart  of the  hernial  sac."
 (Scarpa, Traite" des Hernies, p 61, &c.)
   The hernial sac is commonly described
 as an elongation of peritonaeum.  When
 more minutely examined, however, it  is
 found, in cases of inguinal hernia, to con-
 sist of the portion of peritonaeum, pushed
 out with the viscera ;  of a layer of cellu-
 lar substance on the outside of this, which
 becomes more or  less thickened by the
 pressure ofthe rupture in different cases ;
 of a fascia, sent off from the tendon of the
 external oblique muscle; and of the cre-
 master  muscle, which latter parts form
 the exterior covering,  which consisting of
 several layers, often leads the operator to
 fancy he lias opened into the cavity of the
 sac, when, in reality, he has not.
   It  is observed by Professor Scarpa, that
 "the cremas er muscle,  in  cases of old
 large scrotal herniae, acquires a thickness,
 which  is  really surprising.   Its fibres,
 which  are  naturally very thin, become
 from f >ur to six times more considerable.
 Being spread over  the neck  and body of
 the hernial sac, they sometimes present a
 remarkable consistence, and a yellowish
 colour.   Such alteration, however,  does
 not prevent the muscular  texture from
 being discovered, and Haller was not mis-
 taken about it.  ( Opusc. Patholog. p. 317.)
 Pathology furnishes us with several ex-
 amples of similar changes of organization.
 In certain c-ises, the muscular coat ofthe
 bladder, that of the stomach and intes-
 tines, and even the exceedingly delicate
 fleshy fibres of the ligaments of the colon,
 are  "found  to  have become yellow, and
 much thickened.
   " In old scrotal herniae (says Scarpa)
 it is not unusual to find an intimate ad-
 hesion of the fibres of tlie cremaster mus-
 cle to the  edges  of the abdominal ring.
 This may depend on the pressure,  which
 the contents of the hernia  may make on
 those edges, and  perhaps it may also de-
 pend on the union of the cremaster mus-
cle with tlie prolongation of the aponeu-
rosis ofthe fascia lata, which is continued
from tlie margins of the ring to the groin
and scrotum.  Howsoever it may be, cer-
tain it is, that in old large scrotal herniae,
there is much difficulty in introducing a
probe between the fleshy fibres of the cre-
master  and the margin ofthe abdominal
ring; and that, on the contrary, in recent
herniae, a probe passes as easily between
the edges of the ring and the cremaster,
as between  this muscle and  the hernial
sac.
  "Few authors  (according  to  Scarpa)
have spoken ofthe sheath, formed by the
cremaster muscle, in which are enclosed
the hernial  sac, the spermatic cord, and
the tunica vaginalis ofthe testicle. Sharp
(In  Critical Enquiry) and Monro, the fa-
ther, (Anat. and Chirurg. Works, p. 553.)
were the first to dwell  upon this import-
ant pathological point.   Monro had seen
the cremaster muscle covering the hernial
sac; but, he did not believe, that the same
thing occurred in all individuals affected
with inguinal hernia.  In this respect, he
was mistaken; for, this disposition of the
cremaster muscle is  one or the essential
characters of the  disease.  Petit has not
omitted to describe the relations, which
exist between the cremaster and the herni-
al sac.  ((Euvres Post hum. Tom. l.p. 288.)
On  this subject,  he even relates an inter-
esting fact, from which it results, that, in
certain cases, this muscle may by its con-
tractions alone cause a  reduction of the
hernia.   Gunz  explains, with tolerable
perspicuity,  how the cremaster  and  its
aponeurosis  form one of the coverings of
the inguinal and scrotal hernia.  (Libelius
de Herniis,p. 50.)  Morgagni once saw  its
fleshy fibres  extended over the hernial sac;
(De sed. et  caus. morb. epist. 34, art.  9;
epist. 31, art. 15.) andNeubaver positively
assures  us, that he has made the same re-
mark upon the dead body of a man affect-
ed with an entero-epiplocele.   (Dessert de
Epiploo-oscheocele.)  After these facts,  so
positive and accurately observed, I can-
not comprehend (says Scarpa) how in our
time Pott, Richter, and several other au-
thors, should have passed over in silence,
or only mentioned vaguely, this point,  so
important in the history of the inguinal
and  scrotal hernia."   (Scarpa, Traite' des
Hernies, p. 48—50.)
  When surgeons  speak of a  hernial sac
being usually thicker  and stronger,  in
proportion to the magnitude and duration
ofthe hernia, they do not imply, that this
alteration only occurs in the mere perito-
naeum.    '
  In very enormous hernia, the pressure
ofthe contents is so great, that, instead of 
HERNVIA.
65
 thickening the sac, it renders it thinner,
 and  even makes it  ulcerate.  The  pro-
 truded viscera have been met with imme-
 diately beneath  the  integuments, when
 the sac has been burst by a blow. (Cooper;
 J. L. Petit)
   The outer surface of the peritoneal part
 of the hernial sac, is always most closely
 adherent to the other more external cover-
 ing by means of cellular substance.  This
 connexion is formed so soon* after the first
 occurrence of a hernia, that any hopes of
 returning a hernial sac into the abdomen
 are now  generally considered as merely
 chimerical.  There must, however,  be a
 certain space of time, before adhesions
 form, though it is, ho doubt,  exceedingly
 short.
   Upon this point, Scarpa does not adopt
 the opinion commonly received.
   " It has long  been disputed, (observes
 this author) whether it is possible to re-
 duce a hernial sac into the abdomen with
 the intestine.  But, it has happened, as
 in most discussions,  that  every  one has
 endeavoured  rather to support  his  own
 opinion, than appreciate the facts opposed
 to him.   On both sides,  they have neg-
 lected to  consult observation, which alone
 ought to  be the basis of our judgment in
 similar matters.
   " There is no doubt, that, in recent and
 small inguinal herniae, the intestine, stran-
 gulated by the heCk ofthe hernial sac, has
 been known, in more instances than one,
 to. have been reduced by the taxis,  and
 carried with it the Whole of the sac  into
 the abdomen.  Observations,  not less au-
 thentic, inform Us, that,  after the opera-
 tion for hernia,  when the viscera  could
 not be reduced on account of their adhe-
 sions to the sac, they have been seen, not-
 withstanding such adhesions, to get nearer
\o the ring daily, and at length, spontane-
 ously  to  return  into the  belly together
 with  the  hernial sac.  Louis  was wrong
 in denying the possibility of  these facts.
 (Acad. Royalede Chirurgie, Tom. 11 p.486.)
 For my part, (continues Scarpa)  I regard
 them as very correct, according to my own
 experience, and that of several other  sur-
 geons.   It appears, that the illustrious
 secretary  of the academy, only refused to
 put confidence in such well attested cases,
 because they were contrary to an opinion,
 that he had set up with great assurance :
 he pretended that neither art, nor nature,
 could ever accomplish the reduction ofthe
 hernial sac, unless the cellular substance,
 which unites it to the spermatic cord and
 surrounding parts, were torn. Apparently
 he forgot, that, under  certain  circum-
 stances, the  cellular substance will bear,
 without laceration, a considerable elonga-
 tion,  and  afterwards shrink again.  It is
     Vol. 1!
 thus, that we often see a visous, which had
 suffered a considerable displacement, re-
 turn spontaneously into its natural situa-
 tion.   Pathology would furnish us with a
 great number  of similar examples ; but,
 riot to depart from our subject,  daily ex-
 perience proves, that, in the inguinal her-
 nia, the spermatic cord is elongated, and
 descends farther, than in the natural state.
 No laceration of the cellular substance,
 however,  is then occasioned; for,  if the
 hernia be  kept reduced, the spermatic
 cord becomes shorter, daily retracts, and
 at last has only the same length, which it
 had previously to the disease.  When a
 sarcocele  becomes  large and heavy,  tlie
 portion  of the  spermatic cord, naturally
 situated within the belly, is by degrees
 drawn out into  the scrotum; but, after
 the tumour is extirpated,  this portion as-
 cends again, and of itself returns into its
 original situation.
  "The same  thing happens  after  the
 operation  for  the strangulated inguinal
 hernia.  All  practitioners have noticed,
 that the  hernial sac retracts and reas-
 cends  progressively towards the ring.
 That  alone would prove, that the cellu-
 lar substance, Which surrounds  the sper-
 matic cord* and  unites. It t» the hernial
 sac, is highly endued with the property of
 yielding* and afterwards returning to its
 original state.   Can the same property be
 refused to the cellular substance, which
 unites the sac to the cremaster muscle and
 other surrounding parts ?
  " While the inguinal hernia is recent*
 and not of much size, the  cellular sub'
 stance in question possesses all its elasti-
city, and  hence,  the hernial sac and the
 spermatic cord, may easily ascend towards
 the abdominal ring.  I have had occasion
 (says  Scarpa)  to make this observation
 upon the dead body of a man, who had an
 incipient inguinal hernia.  The small her-
 nial sac was capable of being pushed back
 into the ring with the utmost facility; and
 in carefully examining the parts* both
 within and Without the belly, it appeared
 to me, that the cellular substance, which
 united the sac  to the spermatic cord and
 cremaster muscle, was disposed to yield
 equally from without inwards, and in the
 direction  precisely opposite;  that is  to
 say, it made an  equal resistance  to the
 protrusion and the reduction of the her-
 nial sac.   Monteggia has seen a case ex-
 actly  similar s although, according to his
 own expressions, (Instituz. Chirurg. Tom.
 3, sex. 2, p. 249.) the hernial sac was not
 very small, it adhered very loosely to the
 surrounding parts, and it admitted of be-
 ing entirely  reduced into the  abdomen
 with  great facility.  It might indeed  be
 strict!v said, that this is not a true redu.6--
    i" 
66
HERNIA.
tion, because in pushing back the  hernial
sac, we only just squeeze it up behind the
ring, whence it is forced out again by the
slightest effort.  But, whatever we may
please to term this retrocession of the her-
nial sac, it is not the less proved, in  an
evident manner, that, in the small and  re-
cent inguinal hernia, the  hernial sac,  to-
gether with the viscera Which it contains,
may be returned into the abdomen.
  " Tlus is not the case with large old
scrotal herni ae.  In these, the cellular sub-
stance, which unites the sac to  the sper-
matic cord, and cremaster muscle, has  ac-
quired such a density, that it does not op-
pose less resistance  to the further deve-
lopement of the hernia, than to the efforts
of the surgeon, who endeavours to effect
it9 reduction." (Scarpa, TraitS des Hernies,
p. 57, &c.)
  We  shall   conclude  this anatomical
account  of the  inguinal  hernia,  with
ihe following explanation of the parts
as they appear on dissection:  "  the  re-
moval of the integuments  exposes the ex
terior investment of the hernial tumour,
continuous with the  margins of the ring,
and formed of tendinous fibres, from  the
aponeurosis,  the cremaster muscle,  &c.
This is connected by  cellular substance
with the proper hernial sac, formed of  the
peritonaeum.   This  production  of  the
peritonaeum passes through the  ring of
the external oblique, and then goes  up-
wards and outwards.  Behind  and above
the ring, the  inferior margin of  the  ob-
liquus mtemus and  transversalis  Icrosses
the neck ofthe sac.  When these muscles
are reflected towards the linea alba,  the
fascia,  ascending from  Poupart's  liga-
ment, anil  forming  the upper opening of
the ring,  is expo-ed, and the epigastric
artery is discovered  emerging from  the
inner side  of the neck ofthe hernial  sac,
(Camper;) which,  at this precise point,
becomes continuous with the peritonaeum,
lining the  abdomen.  The removal ofthe
hernial sac will disclose the course ofthe
spermatic  cord in its  de cent  towards
the testicle; and  when this is also  ele-
vated, the first part of the course of the
epigastric  artery, and its  origin frr.m the
iliac  trunk, are I.t.d  open."  (Lawrence
onHernia,p  115, 116)
   Iivfemales, the  round ligr.ment of the
uterus bears the same relation to the tu-
mour, as the tpe1 rnatic cord in males.   In
the former subjects, bubonoceles are un-
common.  Mr. f^awrence had a very  rare
instance pointed out to him, in which a
bubonocele in n female was situated on
the inner side of the epigastric artery.

 MARKS OF DISCRIMINATION BETWEEN SOMB
  OTHER i)ISXASES AND INGUINAL HERNI*.
  The disorders in which a mistake may
possibly be made, are the Cirsoeele, Bubo,
Hydrocele and  Hernia Humoralis,  or In-
flamed Testicle.
  For an account of the manner of distuv
guishing the first complaint from a bubo-
nocele, see Cirsoeele.
  " The  circumscribed  incompressible
hardness, the situation of the tumour, and
its being free from all connexion with the
spermatic process, will sufficiently point
out the first, at least while it is  in a re-
cent  state ; and when it  is in  any degree
suppurated, he must have a  very small
share of the tactus eruditus,  who cannot
feel the difference  between matter,  and
either a piece of intestine, or omentum.
  " The perfect equality of the whole tu-
 mour,  the freedom  and smallness of the
spermatic process above it, the power of
feeling the spermatic vessels and the vas
deferens in that process, its being void of
pain  upon being handled, the fluctuation
of  the water,  the gradual formation of
the swelling, its having begun below  and
 proceeded upwards, its not being affected
 by any posture or action of the patient,
 nor increased by  his coughing or  sneez-
 ing, together with the absolute  impossi-
 bility of feeling the testicle at the bottom
 of  the scrotum, will always, to an intel-
ligent person, prove the disease to be a
hydrocele."  Mr. Pott,  however, allows,
 that  there are some exceptions, in which
 the testicle cannot be felt at the bottom of
 the scrotum in cases of hernia.  In re-
 cent bubonoceles, while the hernial sac i9
 thin, has not been  long,  or  very much
 distended, and the scrotum still preserves
 a regularity of figure,  the testicle  may
 almost always  be easily felt  at the infe-
 rior  and posterior  part of*  the tumour.
 But,  in old ruptures,  which have been*
 long down, in which the quantity of con-
 tents is large, the sac considerably thick-
 ened,  and  the  scrotum of an  irregular-
 figure, the testicle frequently cannot be
 felt, neither is it in  general easily  felt  in
 the congenital hernia for obvious reasons."
 (Pott)
    "  In the hernia humoralis,  the pain in
 the  testicle,  its  enlargement, the hard-
 ened state  of the epidydimis, and the
 exemption of the  spermatic cord  from
 all unnatural fulness, are such marks as
 cannot easily  be mistaken;  not to  men-
 tion the generally  preceding gonorrhoea.
 But, if any doubt si^l remains ofthe true
 nature of the  d'sea', the progress  of it
 from above downward,  its different  state
 and size in different postures, particularly
 lying and standing, together  with its de-
 scent and ascent,  will, if duly attended
 to;  put it out of all doubt,  that  the tu-
 mour is a true hernia."   (Pott.) 
HERNIA-                                <£
  When an inguinal hernia does not de-
scend through the abdominal  ring, but
only into the canal tor the spermatic cord,
it is covered  by the aponeurosis of the
external oblique muscle, and the swelling
is sm. 11 and undefined.
  Now  and then, the testicle  does not
descend into the scrotum till a late period.
The first appearance of  this body  at the
ring, in  order to get into its natural si-
tuation, might be mistaken for that  of a
-hernia, were the surgeon  not to pay at-
tention  to the absence ofthe testicle from
the scrotum,  and the peculiar sensation
•ccasioned by pressing  the swelling.

OPERATION FOR  THE STRANGULATED IN-
    GUINAL HERNIA, OR BUBONOCELE.

   This consists in  dividing the integu-
ments ; dissecting down to the sac, and
opening it; removing the stricture; and
replacing the protruded viscera.
   The external  incision should begin an
inch above the external  angle of the ring,
and extend over the middle ofthe tumour
to its lower part. The advantage of be-
ginning the  wound so  high, is to obtain
convenient room for the  incision of the
 stricture.  By this first cut,  the external
pudic branch of the femoral artery may
be divided; it  crosses the  hernial sac
 near the abdominal ring, and  sometimes
bleeds  so freely, that it should be imme-
 diately tied.  In general, however, a hga-
Jnre is  unnecessary.
   When carrying this incision  low down,
 we should always bear in  mind the cau-
 tion  given  by  Camper, that there is a
 possibility of dividing the spermatic ves-
 sels, should they happen to be situated,
 as they sometimes are, in front of the
 hernia.  The division of the integuments
 brings into view the fascia,  which is sent
  off from the teisdon ofthe external oblique
  muscle, and covers the hernial sac.
   The layers of tendinous fibres,  cellular
  substance, &c.  intervening  between the
  skin and sac, should be carefully divided,
  one  after another, with  the knife and
  dissecting forceps, taking care" to incline
  the edge of the instrument horizontally,
  for fear of cutting too deeply at once, and
  injuring the viscera contained in the sac.
    After making a small opening  through
  a  part of tlie fascia  covering the sac,
  some advise introducing  a  director, and
  laying it open  upward and  downward as
  far as the  tumour extends.   The same
  manner of proceeding, they next recom-
  mend in regard to the cremaster muscle.
  Thus  the sac becomes completely  expos-
  ed.   When this method is  followed,  Mr.
  A. Cooper advises the  incisions not to be
  Carried upward, nearer, than one inch, to
the abdominal ring, for reasons which
will be presently explained.
  However it may be rationally doubted,
whether there 1s any good in these regular
and  successive divisions of tlie  whole
length of  the coverings of the sac: and
it is certain, that they protract the  opera-
tion  very much.   As  the  grand object,
after  dividing  tlie  skin, is  to make a
small opening into the  sac, sufficieut  for
the introduction of  a director, dissecting
down  at  one  particular place, answers
every purpose, and  enables us, in the end,
to lay open the whole  of die sac and its
coverings in the shortest time.  Let  the
operator only take care to raise the suc-
cessive layers of  fibres with the forceps,
and divide the  apex of each elevated por-
tion with the  knife  held horizontally.
As there is commonly a quantity of fluid
in the sac, and it gravitates to  the  lower
part, to which place the intestine seldom
quite   descends;  this  is certainly  the
safest situation for  making the  first open-
. ing into the sac.  The operator, however,
relying on the presence  of such fluid,
 should not cut  too boldly;  sometimes
 none at all i»  found, and the  viscera are
in immediate contact with, nay, adherent  ,
to, the inner surface of the sac.
   The circular arrangement of the  ves-
 sels of a piece of intestine, and its smooth
 polished surface, sufficiently distinguish
 it from the hernial sac, which has a rough
 cellular surface, and is always connected
 with the surrounding parts.   (Lawrence,
 p. 125.)
   We have mentioned, that Mr. A. Cooper
 only advises cutting the fascia, and other
 coverings of the sac, under the skin, to
 within an inch  of the abdominal ring:
 he  also recommends,  of course, limiting
  the division of the sac itself to the same
 extent.  His  reasons, for this practice,
  are to avoid  making the closure of the
 wound more difficult, and to lessen the
 danger of peritoneal inflammation.
    Having laid open the hernial sac, with
  a probe-pointed bistoury, guided on a di-
  rector, or tlie fore-finger, introduced into
  the opening, which is made at the lower
  part ofthe sac, the next desideratum is to
  divide the stricture, unless  the  viscera
  admit of being  easily  reduced,  without
  such an incision being made, as occasion-
  ally happens.
    From the  anatomical account we have
  given of the bubonocele,  it appears, that
  the  stricture may either be situcied at
  the abdominal  ring,  and be formed  by
  the margins of this  opening, or else at
  tlie  inner aperture of  tlie  canal, about
  one  inch and a  half, in a direction up-
  ward and outward, from the  outer  open-
  ing in the tendon of  the external oblique 
68
HERNIA.
 muscle.  This  latter  strangulation  is
 caused by the semicircular edge of the
.transversalis muscle and its tendon, which
 pass over the  neck of the hernial sac, and
 by a fascia, arising from Poupart's  liga-
 ment,  the semicircular border of which
 passes under this part of the sac.
   The common,  and probably the best,
 practice is to  divide the hernial  sac, iO-
 gether with the stricture. When this is sir
 tuated at the abdominal ring, the surgeon
 is to introduce the end of a director a
 little way into the neck of the sac, within
 the aperture  in the tendon, and  with a
 {irobe-pointed   bistoury, guided  on the
 atter instrument, he is to cut the stricture
 Upward and outward, or else directly up-
 ward;  a manner,  which Mr.  A. Cooper
 recommends because  it is applicable to
 all Cases, even those  less frequent ones,
 in  which  the hernia  protrudes  on the
 inner side of the epigastric artery.  This
 vessel,  as we  have  already  explained,
 commonly  runs upward round the inner
 side of the neck of the sac ; so that cut-
 ting the stricture upward and  inward
 Would be very apt to divide it.
   Cutting upward and outward is, in or-
 dinary cases,  perfectly safe; and is  only
 objectionable  in  a  few  occasional  in-
 stances, in which  the hernia descends on
 the  inner side of the' artery.  Mr. A.
 Cooper's rule of always cutting  in one
 direction, viz, upward, which is  proper
 in every instance,  is in mv opinion  well
 worthy of universal adoption.  No more
 ofthe parts, forming the stricture, should
 be cut, than is just sufficient for allowing
 the protruded viscera to  be reduced,
 without  bruising  or   otherwise  hurting
 them.   The middle of  the upper margin
 of the r'mg is  the safest place for  making
 tlie necessary  incision.
   Mr. A- Cooper, in his late work on the
 Inguinal Hernia, advises a mode of divid-
 ing  the  stricture,  considerably different
 from the usual method.  He  directs the
 finger of the  operator to be  introduced
 into the sac, (which in his plan, we know
 is left undivided for the space of one inch
 below the ring.)   When the  stricture is
 felt, a probe-pointed bistoury is to be con-
 veyed  over the front  of the sac into the
 ring (between the  two parts,) and the lat-
 ter only Is then to be divided, in the di-
 rection upward,  opposite the  middle of
 the neck ofthe sac, and to an extent just
 sufficiently to  allow the protruded parts to
 he returned into  the  abdemen,  without
 their being hurt.   The two chief advan-
 tages,  which  Mr. A. Cooper  imputes  to
 this method, are, that the danger of peri-
 toneal inflammation will be less, and that
 the epigastric artery,  if wounded, would
 pot  bleed  into the abdomen.  I  am  of
opinion, that what Mr. Lawrence has re*
marked, concerning this  proposal, is ex-
ceedingly judicious :  " An accurate com.
parative trial of both methods  would be
necessary, in order to determine the weight
of the first reason.  The second  circum-
stance cannot be a matter of any import-
ance, if we cut in such a direction  as to
avoid the risk of wounding the artery.
Many circumstances  present themselves
as objections to this proposal.   The ma-
noeuvre  itself,  although perhaps easy to
the  experienced hand of  such an  able
anatomist as Mr. C.  would,  I am  con-
vinced, be found highly  difficult, if not
impracticable,  by the generality of sur-
geons.  This  difficulty  arises  from the
firm manner, in which the sac and sur-
rounding parts are  connected,  we might
almost say, consolidated  together.   The
experience of Richter ('Traitif des ffernies, '
p. 118) shews, that this objection is found-
ed in real it}'.   He once tried to divide the
ring, without cutting ihe sac, but he found
H impracticable.  If the  stricture  is so
tight, as to prevent the Introduction of
tlie finger, there must be great danger of
wounding the protruded parts.  The prac-
tice would still be not advisable, even if
it could be rendered as easy as the com-
mon method of operating.   Mr. C. leaves
an inch of the sac, below the ring,  undi-
vided ; thus  a  bag remains ready to re-
ceive  any future  protrusion,  and the
chance  of a  radical cure  is diminished.
It would be better to follow the advice of
Richter, and scarify the neck of the sac,
in order  to  promote  an  adhesion  of its
sides.   He  has  found this practice so
successful in  accomplishing  a radical
cure, that he advises (p. 191.) its employ.
ment in every operation for strangulat-
ed  hernia."    (Treatise   on  Hernia, p.
144.)
   If'.he stricture should be felt to exist
at the inner opening of the canal for the
spermatic cord, Mr. A, Cooper advises the
operator to introduce  his finger into the
sac, as far as the stricture, and then to
insinuate  a probe-pointed bistoury,  with
the flat part of its blade  turned towards
the  finger, between the  front of the sac
and the abdominal ring, till  it arrives
under the stricture, formed by the  lower
edge ofthe transversalis and obliquus in-
terims.   Then the edge of the instniment
is to be turned forward,  and the stricture
cut in the direction upward.  This plan of
not cutting the neck ofthe sac, is liable to
all the objections stated by Mr. Lawrence,
in regard to the case,  in which the  stran-
gulation takes  place  at  the  abdominal
ring  It should  be mentioned, that Mr
A. Cooper's bistoury  is a very proper one
for dividing the stricture, as it only ha* a 
HERNIA.
69
cutting edge to a certain distance from
the point.  Perhaps, on tiie whole, we may
infer, that it is both most easy and advan-
tageous to divide the neck of the sac,  to-
gether with the stricture, whether this be
situated at the ring,  or more inward.  In
the latter cVise,  cutting upward  and out-
ward would always be perfectly  safe,  be.
cause the hernia "always protrudes on tlie
outer side ofthe epigastric artery; but, as
it is easiest for the memory to adhere to
one rule, making the incision immediately
upward is a very proper plan,
   Room being made for the reduction of
the protruded parts into the abdomen, by
the division ofthe stricture, they are to be
immediately returned, if sound,  and free
from adhesions.   This object is  consider-
ablv facilitated by bending the thigh. The
intestines are to be  reduced before  the
omentum, but, when a portion of mesen-
tery is protruded, it is to be returned be-
fore either of the preceding parts.  The
intestine should always be reduced, unless
it be found  in a state of actual mortifica-
tion. It often appears so altered in colour,
that an uninformed person would deem  It
improper to return  it into  the abdomen.
However, if such alteration should  not
 amount to a real mortification, experience
justifies the reduction ofthe part.  Mr. A.
Cooper has judiciously cautioned the ope-
 rator not to mistake  the  dark chocolate-
 brown discolourations, for a state of gan-
 grene. With these  the protruded part  is
 frequently  found affected;  and, as they
 generally produce no permanent mischief,
 they ought to be carefully discriminated
 from  the black-purple,  of  lead-coloured
 spots, which usually precede mortification.
 To determine  whether  a  discoloured
 portion of  intestine  be positively  morti-
 fied, some  recommend pressing forward
 the blood contained in the veins, and, if
 they fill  again,  it is looked upon as a
 proof, that the bowel is still possessed of
 life.  '
   In  returning a piece of intestine  into
 the abdomen,  the surgeon should first  in-
 troduce the part, nearest  the  ring, into
  this aperture, and hold  it there till an-
  other  portion  has  succeeded  it.   Tins
  method w> to be followed up, till the whole
  ofthe protruded bowel is reduced.
    Writers  on surgery cannot too severely
  reprobate the employment  of  any force,
  or  violence,  in endeavouring  to return
  the contents of a hernia in  the operation:
  a method  the more pernicious,  because
  such parts are commonly more or less in
  a state  of inflammation.   It  is  always
  more  judicious to enlarge the stricture,
  than to pinch and bruise the bowel in
  trying to get it through  an opening which
  U too small.  Distention of the intestine
sometimes prevents the reduction: but,
the bowel can then be generally returned
as soon as its contents are first compress-
ed  into the part of the intestinal canal
within the stricture.  It is better, how-
ever,  to dilate  the  strangulation  a little
more,  than to use any force  in trying to
get the intestine back  into the abdomen
in the manner just suggested.
  Reduction  is  sometimes impeded  by
the  protruded parts  adhering  to each
other, or to  the hernial sac.   The intes-
tines  are not often found very firmly ad-
herent together.  The omentum  and in-
side of the  sac are the parts, which are
most  subject to become intimately con-
nected by adhesions.   The  fingers will
commonly  serve for breaking any recent
slight adhesions  which may have taken
place  between the intestines and inside
of the hernial  sac.  When  these adhe-
sions  are firm,  and  of long standing,
they must be cautiously divided with the
knife; an object, which can be most ea-
sily and safely accomplished, in case they
are long enough to permit the intestine to
 be elevated  a little  way from the surface
 of the sac.   But, provided their firmness
 and shortness  keep the external  coat of
 the bowel and inner surface  of the sac in
 close contact,  the greatest  care is requi-
 site in separating the parts  with a knife,
 so as to avoid  wounding the  intestine.
 In doing this, the most prudent and safe
 method, is not to cut  too near the bowel,
 but rather  to  remove  the adherent parts
 of the sac,  and return them with the in-
 testine into  the abdomen.   Every preter-
 natural connexion should always be  se-
 parated, before the viscera  are reduced :
 Mr.  A. Cooper mentions,  that  a fatal
 obstruction  to the passage  of the  intes-
 tinal matter has arisen from the  mere
 adhesion of the two  sides  of a fold  of
 intestine together.  (P. 31.)  When the
 adhesions,  which prevent reduction,  are
 situated about the neck of the sac, so as
 to be out of the operator's view,  it is  the
 best  to make the wound through the skin
 and  abdominal ring somewhat larger,  io
 as to be able to separate the adhesions
 with more safety.
    Having reduced the parts, the operator
 should introduce his finger, for the pur-
 pose of being sure that they are fairly and
 freely returned into the abdomen, and no
 longer suffer constriction, either from the
  inner opening, from the ring, or the parts
 just  within  the cavity ofthe peritonaeum.

       TREATMENT OF THE OMENTUM.

    In an entero-epiplocele,  this  part, if
  healthy and free from gangrene, is to be
  reduced after the intestine.   When, how- 
70
HERNIA.
 ever, it is much diseased, thickened, and
 indurated, as it frequently is found to be,
 after remaining any considerable time in
 a hernial  sac,  the morbid part should be
 cut off   Its reduction, in this circum-
 stance, would be highly improper, both
 because an immediate enlargement  of the
 wound would be necessary,  in order lo be
 able to put the diseased mass back  into
 the abdomen, and because, when reduced,
 it would, in all probability,  excite inflam-
 mation of the surrounding  parts,  and
 bring on dangerous  symptoms. (See Hey,
p. 172 )
  The diseased omentum  should always
 be cut off with a knife;  and, if any  of its
 arteries should bleed, they ought  to be
 taken up with  a tenaculum, and tied se-
parately with a small ligature.  An un-
reasonable apprehension of hemorrhage
from the cut end of the omentum has led
many  operators  to put a  ligature all
round this part, just above the diseased
portion, which  they are about to remove.
This  practice cannot be reprobated in
terms  too severe;  for, a frequent  effect
of  it is to bring on a fatal inflammation,
and even  mortification of the omentum,
extending within  the abdomen, as  high
as the stomach and transverse  arch of the
colon.  Mr. A. Cooper has remarked with
great truth,  that  it  is  surprising, this
custom should ever have prevailed.   The
very object of the operation is to  extri-
cate the omentum  from  its strangulated
state, arising from  the  pressure of the
surrounding tendon, and no  sooner has
this been done, than the surgeon includes
it in a  ligature, which produces a  more
perfect constriction,  than that  which
existed before the operation was under-
taken.
  " When the omentum   has suffered
strangulation for  a few days  (says Mr.
Lawrence), it  often becomes  of a dark
red, or livid colour; and there is an ap-
pearance,  on cutting it, as if some blood
were extravasated in its substance.  This,
I believe, is the  state,  which surgeons
have generally described under the term
of gangrene."   (P.  167.)
  When  cut in this state, it does  not
bleed.  I  need  hardly observe, that the
dead jiart must be amputated, and  never
reduced.  Some have advised  leaving the
omentum in the wound, especially in cases
of old hernhe, in which it lias been a loog
while protruded.   Hey  mentions  cases,
shewing that granulations form very well,
and the  wound becomes firmly healed,
when this plan is followed.   (P. ISO, &c.)
Every one, however, will acknowledge the
truth of what Mr. Lawrence says on this
sufcject.  The  method " is attended with
no particular advantage, but certainly ex-
poses the patient to the  possibility of ill
consequences.  The omentum, left in the
wound, must  be liable to injurv, jnflam-
mation, or  disease; and  hence arises a
source of danger to the patient.  Unnatu-
ral adhesions, formed by this part, have
greatly impaired  the  functions  of . the
stomach.  Cases are recorded, where the
unfortunate  patient has never been able
to take more  than a certain quantity of
food, without  bringing on instant vomit-
ing: and even where it has been necessary
for all the meals to be taken in the recum-
bent position, with the tnunk curved, and
the thighs bent.  (Gunz.)  To  avoid the
possibility of such afflicting consequences,
we should,  after removing any diseased
portion, carefully replace the sound part
of the omentum in  the abdominal cavity."
(Treatise on Hernia,p. 181.)

  TREATMENT, WHEN THE INTESTINE IN
        TUE SAC MAS MORTIFIED.

  Sometimes,  on opening the hernial sac,
the intestine is found to be in a gangren-
ous, state,  although the occurrence could
not be previously  known, owing to the
integuments and the  hernial  sac itself
not being affected with the same mischief.
In ordinary cases, however, both tlie skio
and sac become gangrenous at the same
time with  the contents of the  hernia.
The tumour, which was before tense and
elastic, now becomes soft, doughy, em-
physematous,  and  of  a purple  colour.
Sometimes the parts now become spon-
taneously reduced;  but, the patient only
survives a few  hours.
  Mr. A. Cooper has accurately remark-
ed,  that,  in other instances,  the  skin,
covering the swelling, sloughs to a con-
siderable extent, the intestine gives way,
and, as the feces find vent at the wound,
the symptoms of strangulation  soon sub-
side. When the patient continues to live
in these circumstances, the living part of
the intestine becomes adherent to the her-
nial sac, the sloughs separate  and come
away, and thus an artificial anus is esta-
blished, through which the feces are com-
monly discharged, during the remainder
of life.  (See Anus, Artificial.)
   However, though when the patient sur-
vives the mortification of an  intestinal
hernia, he  commonly obtains  the bless-
ings of life only combined with the loath-
some affliction of an artificial anus ; yet,
things  sometimes take a still more  pros-
perous  course;  the feces gradually re-
sume their  former rout to the rectum,
and, in proportion  as the artificial anus
becomes unnecessary, it is shut up. Many
instances of this sort have fallen under
my own observation in St. Bartholomew's 
HERNIA.
7V
 hospital.  The  chance of  a favourable
 event is much greater in some kinds of
 hernia,  than in others.  When the su-an-
 gulation only includes a part of the dia-
 meter of the gut, the feces are sometimes
 only  partially  discharged  through  the
 mortified opening.  This quantity lessens,
 as the wound heals, and the patient  gets
 perfectly well.   (Louis; Mem. de tAcad.
 de  Chir. Tom.  3.)   A small gangrenous
 spot, or two, may end in  the  same man-
 ner.  Mortification of  the  csecum  and
 its  appendix,  in a  hernial sac, has hap-
 pened several times, without much dis-
 turbing the usual course of the feces  to
 the anus, and the patients have very soon
 recovered.  (Med.  Obs. and Inq. Vol.  3,
 p. 162, &c.)
  The grand thing, on which tlie esta-
 blishment of tlie continuous state of the
 intestinal canal depends, in all these cases,
 is the adhesion, which the living portion
 ofthe bowel, adjoining the mortified part,
 contracts with the peritonaeum all round.
 In this manner, the escape of the contents
 of the bowels into the cavity of tlie peri-
 tonaeum becomes in general  completely
 prevented.   When the intestine has not
 already burst,  the  stricture  should be
 divided; an opening made  in the  morti-
 fied part to let out the feces, and very
 mild purgatives and glysters administered.
 (Lawrence, p. 186.)
  It is an observation of Mr. A. Cooper's,
 that the degree of danger,  attending an
 artificial anus, depends on tlie vicinity of
 the  sphacelated  part of the intestinal
 canal to the stomach.  Thus, if the open-
 Ing be  in the jejunum, there is such a
 small extent of surface  for  absorption,
 between  it  and the stomach, that the
 patient dies of inanition.
  Let us now suppose, that  the mortified
 state of the intestine has only been  dis-
 covered,  after laying open the hernial sac
 in tlie operation.  The mischief may only
 consist of one,  or more spots; or of the
 Whole diameter of the protruded bowel.
 In the first case, the  proper practice is to
 divide the stricture, and return  the in-
 testine into the abdomen, with tlie mor-
 tified spots towards the  wound.  Mild
 purgatives  and glysters are then to be
 exhibited.  The most  favourable mode,
 in which  a case of this  kind ends, is,
 when the intestinal matter gradually re-
 sumes its  natural   course,  after  being
 either partly, or entirely discharged from
 the wound.  But, sometimes, an artificial
 anus continues for life.
  The repeated observations  of modem
surgeons have now decided,  that no liga-
ture,  passed through the mesentery, to
keep  tlie gangrenous part of the bowel
 uear the wound, is at all necessary.  The
 fiarts, in the neighbourhood of the ring,
 iave all become  adherent  together, in
 consequence of inflammation, at tiie same
 time, that the  parts  in the hernial  sac
 mortify-;  and, of course, the  partially
 gangrenous bowel, when reduced, is me-
 chanically  hindered, by these adhesions,
 from slipping far  from tlie wound.  De-
 sault and  De la Faye, both  confirm  the
 fact, that tlie intestine never recedes far
 from the ring; and, even were  it to do
 so, the adhesions, which it soon contracts
 to  the adjacent surfaces, would,  as Petit
 has explained,  completely  circumscribe
 any matter, which might be effused, and
 hinder it from being  extensively extra-
 vasated  among the convolutions of  the
 viscera.  (Mem. de I'Acad de Chir. Tom.
 land 2.)
   Mr. Lawrence, in his bite very valuable
 Treatise on Hernia, has clearly shewn  the
 impropriety of sewing the ends of  the
 intestinal canal together, introducing one
 within the other, supported by a cylinder
 of isinglass, &c. put in their  cavity, in
 those  cases, in which the whole circle
 of the intestine has mortified,  and been
 cut away,  as is advised  by the majority
 of writers.  "  By drawing  the  intestine
 out of the  cavity, in order to remove  the
 dead partj the adhesion behind the ring,
 on which the prospect of a cure chiefly
 depends,  must be  entirely  destroyed;
 and new irritation and  inflammation must
 be unavoidably produced,  by handling
 and sewing an inflamed part."—(P. 199.)
   Instead  of such  practice,  this gentle-
 man very judiciously recommends dilat-
 ing the stricture,  and leaving the subse-
 quent progress of the cure entirely tn
 nature.  The sloughs  will cast offi and
 the  ends of the gut are  retained by the
 adhesive process in a state of apposition
 to  each  other, the most favourable  for
 their union.  Thus, there is a chance of
 the  continuity of the intestinal  canal  be-
 coming established again.
  However, in  recent wounds of the  ab-
 domen, attended with  a protrusion of a
 portion of  ihe  intestine, cut completely
 across,  the bowel is  as  yet neither  in-
 flamed,  nor adherent  to  the vicinity of
 wound in the  peritonaeum,  so  that, in
 these cases, it may be proper practice to
 connect the ends together, (as advised in
 the  article Abdomen,  Wounds of the  In-
 testines,)  by means of a few stitches with
 silk, or thread, and a small sewing needle;
 and to confine the  wounded  part of the
 intestine, near the breach in the perito-
 naeum, until adhesions have had time to
 form.
  Mr. A. Cooper has  recommended this.
 mode of proceeding in cases of hernia,
attended with mortification of the whole 
n
HERNIA
diameter of the bowel;  but, for reasons,
already stated, and  many facts, referred
to in "Mr. Lawrence's work, it is  to be
hoped, that the plan of sewing the in-
Ustines  in these cases  will be for ever
abandoned.

  OPERATION fOR VERr LARGE INGUINAL
               HEHM.E.

  When the tumour is of very long stand-
ing, is exceedingly large, perhaps extend-
ing half way down to the knees, and its
contents  have never admitted of  being
completely reduced,  the indication is  to
divide the stricture, provided  a strangu-
lation takes place ;  but without laying
open the hernial sac, or  attempting to re-
duce the parts.
  The reasons, against the common plan
of operating,  under such circumstances,
are, the difficulty of separating  all the old
adhesions; the  hazardous inflammation,
which would be excited by laying open
so vast  a tumour,  and the probability
that parts, so long protruded, might even
bring on serious complaints, if reduced.
J. L.  Petit, and afterwards, Dr. Monro,
advised the sac not  to be opened in ope-
rating on certain  cases.   (See  Mai. Chir.
'Tom. 2,  p.  372.   Description  of Bursx
Mucosx.)

orERATION FOR  THE HERNIA, WHEN IT IS
   SO SMALL THAT IT DOES NOT PROTRUDE
   KXTERNALLT THROUGH THE RINO.

   In this kind of  case, there is little ap-
pearance of external tumour; consequent-
ly, the disease is very apt to be overlooked
by the   patient and surgeon,  and some
other cause  assigned for  the series of
symptoms.  The manner of operating, in
this form of the disease, differs from that
in the common scrotal heniia; the incision
is to be  made parallel to the direction of
the spermatic cord, and the stricture will
be found at the internal ring.  (A- Cooper
on Inguinal Hernia.)

    TREATMENT AFTER THE OPERATION.

   Evacuations from the bowels should be
immediately promoted  by means of glys-
ters,  oleum ricini,  or small doses of any
ofthe common salts, dissolved in pepper-
mint-water.  For some  time, tlie patient
must only be allowed a low diet.  When
symptoms of inflammation  of  the bowels
and  peritonaeum  threaten the  patient,
general  bleeding, leeches  applied to the
abdomen, fomentations, the warm bath,
blisters, doses of the oleum  ricini, and
glysters, are the means  deserving of most
dependence,  and should be resorted to,
without the least delay.  When  all the
danger of peritoneal inflammation is past,
and the patient  is very low and  weak,
bark, wine, cordials, and a generous diet,
must be directed. The effervescing saline
draught, with opium, is the best medicine
for quieting sickness,  after the operation.
Opium and cordials are the most eligible
for checking diarrhcea.  As the opera-
tion  does not usually prevent the  parts
from becoming protruded again, a truss
must  be applied before the patient gets
up again,' and  worn  constantly  after-
wards.
PROPOSALS FOR THE RADICAL  CURE OF TRB
              BUBONOCELE.


   We shall  just  mention the principal
plans for this purpose^ some of them are
perfectly absurd and cruel; others  may
deserve more extensivettrial.  Of castrat-
ing the patient, applying caustic, or of
the operation of the punctum  aureum,
With this view, I need only say, that  they
are barbarous, and not at all adapted for
the attainment of the desired end.  A de-
scription of these methods may be found
in Pare, Wiseman, &c.
  The old  operation, termed the  royal
stitch,  seems one of  tlie  most justifiable.
It consisted in putting a ligature, under
the neck of the hernial sac, close to the
abdominal ring, and  then tying it, so  as to
produce an obliteration  of tlie pervious
state of  the part, by the adhesive inflam-
mation thus excited.  An incision, about
two inches  long,  would be  quite large
enough for getting at the neck of tlie sac,
which must next  be separated from the
parts covering it on  each side, with a few
sweeps of the knife.  A single ligature
might then, with the aid of a needle, be
passed immediately under it, and be-
tween it and the spermatic vessels,  close
to the ring, and then firmly tied, just as
surgeons tie an artery.  This operation
is  applicable to reducible hernia.  One
would not expect d priori, that any dan-
gerous constitutional symptoms would be
likely to follow  so small  a wound,  or
 making a ligature on  a part of such little
 importance as a hernial  sac.  After per-
 forming the common operation for the re-
 lief of a strangulated bubonocele,  might
 not this opportunity be taken, to  learn
 whether a radical cure would  not  more
 frequently be accomplished, than  is  at
 present the case ?
   The royal stitch,  performed in this
 manner, has  actually been attended with
 success.  (Heister,  Vol  TT.)  The  umbi-
 lical rupture  was cured by  Saviaid, on
 similar  principles;  and  Desault radically 
HERNIA.
73
 cured nine cases of the ecomphalos in
 children, by tying the hernial sac.
   Schmucker cured two irreducible rup-
 tures, free from strangulation, by cutting
 away the body of tlie sac, after tying its
 neck.   Chirurgische  Wahrnehumgen,  Vol
 2.)   Mr. A. Cooper, found cutting away
 the sac alone  insufficient, in one case.
   Dissecting away the whole hernial sac,
 or even laying it  open, must be a formi-
 dable operation compared with the sim-
 ple  mo*de above  related.  Such severe
 proceedings would also be quite useless,
 if the hernia were reducible, and the neck
 of the sac could be rendered impervious
 by' the  ligature.  Perhaps  the  cases  re-
 corded by Petit, Sharp, Acrell, &c. against
 attempting a radical cure, have no real
 validity  against the royal stitch  done in
 the simple way above described,  as none
 of these surgeons operated in  this man-
 ner.
   Richter recommends scarifying  the neck
 of the sac, with the view of producing an
 adhesion of  its sides to each other ; a
 plan, which he says, he has found very
 successful.  It certainly seems free from
 danger; but perhaps not more  so  than
 tying the part, and one, would expect,
 less likely to be always successful.
   From the account we have given of the
 anatomy of the bubonocele, it is obvious,
 however, that all these  methods  could
 only obliterate tlie sac as high as the ring,
 not more inwardly to the inner opening.
 Hence there would still remain a certain
 portion of the entrance  of its cavity open
 for tlie descent of the viscera.

      CRURAL, 0R  FEMORAL HERNIA.

   Verheyen, who wrote in 1710,  first de-
 monstrated the distinct  formation of cru-
 ral hernia, which was  before generally
 confounded with bubonocele.
   The parts composing this kind of her-
 nia, are  always protruded  under  Pou-
 part's ligament, and the swelling is situa-
 ted towards the inner part of  the bend
of the thigh.  The rupture descends on
the inside of the femoral artery and vein,
between  these vessels  and the os pubis.
Females  are particularly subject to this
kind of rupture, in  consequence of tlie
great breadth  of  their pelvis, while  in
them the inguinal  hernia is rare.  It has
been  computed,  that  nineteen  out  of
twenty  married  women,  afflicted with
hernia, have this kind;  but, that not one
out of a hundred  unmarried females,  or
out of the same number of mep, have this
form of tlie disease.   (Arnaud.)
  " The  crural hernia," says Scarpa, " is
frequently  observed in  women,   who
liave had several  children; it  very sel-
    Vol. II.
 dom afflicts young girls; and still more
 rarely men.  in the latter, tlie viscera can
 more  easily escape through the inguinal
 ring,  by following the spermatic  cord,
 than they can descend along the  crural
 vessels, and raise the margin of  the apo-
 neurosis of the external oblique muscle,
 that forms  the  crural arch.  In women,
 an opposite disposition  prevails, in con-
 sequence of the smallness of the inguinal
 ring, which, in them, only gives passage
 to the round ligament of the uterus, and
 besides is situated lower down, and near-
 er the pubes, than it is in men, whilst, on
 the  contrary, the crural arch is more ex-
 tensive,  by reason  of the  wider  form of
 the  pelvis.   Morgagni  expressly  says,
 that he  has never met  with the  crural
 hernia in the dead body of any male sub-
 ject.  Mini ut verumfatear, nondum nisi in
 fxminis accidit  ut earn videretn.  (De Sed.
 et cous. morb. Epist. 34—15.) Camper gives
 us to understand almost the same thing.
 (Icones Herniarum, in Prxfat.)   Hevin,
 often operated for this kind of hernia io
 females, but only  once in the male sub-
 ject.  (Puthol. et Therap, p. 406.)   Sandi-
 fort and Walter have both seen  but a
 single instance  of it in the dead body of
 the  male  subject.  (Obs. Anat. Pathol.
 cap. 4,p. 72.  Sylloge comment, anat. p. 24.
 obs.  21.)  Arnaud himself, to whom mo-
 dern surgery is highly indebted for many
 important precepts on the operation for
 the  strangulated crural  hernia  in both
 sexes, candidly confesses, that  he never
 had  an opportunity of dissecting a hernia
 of this kind in  the  male subject." (Scar.
 pa Trait£ des Hernies, p. 201.)
   Scarpa happened to have at  his dis-
 posal the dead body of a man  affected
 with a crural  hernia,  and,  he availed
 himself of the  opportunity of examining
 the parts with the utmost care.   He first
 injected the blood-vessels; he afterwards
 attentively  dissected all  the  parts con-
 cerned in the disease, and, in his valu-
 able treatise, he has published  an exact
 description of all ^ie particulars, accom-
 panied with an  engraving.  Plate 8.
   But, though the occasional occurrence
 ofthe crural heniia in men is fully proved,
 it is  chiefly  in  women, that this  form  of
 disease is met with.
   According to the observations of Scar-
 pa, and all the best modern writers upon
 surgery, the crural  hernia forms, both in
 tlie male and female subject, in  the eel-
 lular substance, which accompanies the
 crural  vessels below Poupart's ligament.
 The  swelling follows tlie internal side of
 those vessels, and gradually descends into
 the fold of the thigh, between the  sarto-
 rius,  gracilis,   and  pectinus  muscles.
" Many surgeons believe,  (says   Scarpa) 
74
HERNIA.
that the  hernial sac, and the intestines,
Which it contains, are ordinarily situated
above the crurd vessels and trunk of tlie
vena  saphen3,  and sometimes  between
these vessels and the anterior  superior
spine of the ilitrm.  But,  as far as my
knowledge extends, this assertion is not
supported by  a single accurate descrip-
tion of a crural hernia in the  early stage.
It is  true, that when the tumour has in
time acquired a large size, and its fundus
is inclined in a parallel manner to the
fold of the thigh,  it partly or entirely
covers the crural vessels,  and eVert the
crural nerve, as Walter says he  once ob-
served.  (Sylloge comment, anat. p.  24.)
But, it is not thence to be concluded, that
(he tumour in the beginning descended
over the  crural vessels, much less betwixt
them and the  anterior superior spinous
ptocess ofthe ilium   Neither must it be
imagined, that the heck ofthe hernial sac
becomes removed from the inner  to the
Outer side of these vessels.   If these two
cases ever  happen,  they must  be  very
rare;  and the best authors, who have
treated of the crural  liernia, concur  in
stating,  that in performing the operation,
they  have constantly  found tiie viscera
situated on the inside of the crural ves-
sels,  hut never on thfir outside.  Evm
when the  tumour, after acquiring a con-
siderable size, Was situated transversely
over the crural vessels, the neck of the
hernial sac has always been found upon
their inner side, that is  to say, between
them and  the pubes.   Le Dran, ( Observ.
de Chir.  Tom. 2,p, 2.)   La Faye\ (Cows.
ef Operations de Dionis,  p.  358.)   Petit,
((Euvres Posthumes,  Tom.  2,  p.  219.)
Morgagnl,  (De Sed. et Caus. Morb.  epist.
34—15.) Arnaud, (Mem. de Chir. Tom. 2.
p. 768.). Gunz, (De Herniis Ubellus.p. 78.)
Bertrandi, (Trnttato delle Operazioni, Tom.
 l,annot. p. 218 ) Pott, (Chirurg.  Works,
 Vol. II,p. 152.) Desault,  ('Traite des  Mai.
 Chirurg. p. 191—195.) B. Bell, (A Sys-
 tern of Surgery, Vol I, p. 387)  Richter,
 (Traite des Hernies, chap. 34.) Nessi, (In-
 stitut. Chirurg. Tom. 2, p. 198 )  Lassus,
 (Med.  Oper. Tom. 1, p. 198.) and many
 other writers,  all concur upon this point.
 In support of their opinion  (says Scarpa)
 I could cite a great number of cases of
 my own, which 1  have collected either in
 operating on several individuals for cru-
 ral hernia, or in dissecting the same kind
 of hernia in  the bodies of many female
 subjects, and  in that of the man,  from
 whom I have taken  the  plate.  Lastly,
 also, having had an opportunity  of dis-
 secting  in a female an  enormous crural
 hernia,  which  descended one-third of the
 way down the thigh, 1 observed, that the
 neck of the sac did not encroach at all
upon the crural vessels, but lay entirely
on their inner side."  (Scarpa, Traite des
Hernies, p. 203—206.)
  The situation of the tumonr  makes it
liable to be mistaken for an enlarged in.
guinal  glafnd; and many fatal events are
recorded to have happened from the sur-
geon's  ignorance of the existence of the
disease.  A gland  can only  become en-
larged by fhe gradual  effects of inflam-
mation ; the swelling of a1 crural hernia
coiries  on  in  a  momentary and sudden
manner,  and, when strangulated, occa-
sions the train of symptoms already de-
scribed in  our account of the  inguinal
hernia,  which  symptoms an  enlarged
gland  could  never  occasion.   Such cir-
cumstances seem to bfe sufficiently dis-
criminative ; though the feel  of the two
Kinds of swelling, is often not  of itself
enough to  make the surgeon  decided in
his opinion.   A femoral hernia  may be
mistaken for a bubonocele,, when the ex-
panded part  of  the swelling lies  over
Poupart's  ligament.   As  the taxis and
operation  for  the first  case ought to be
done differently from those for the latter,
the error may lead to  very  bad conse-
quences.  The femoral hernia,  however,
may always be discriminated, by the neck
of the tumour having Poupart's ligament
ab» \e  it.  In the bubonocele, the angle of
the pubes  is  behind and below this part
of the sac  ; but, in the femoral heniia, it
is on the same horizontal level, and a little
on the inside  of it.   (Lawrence, p. 218)
   In the male subject, " the crural her-
nia, in the early stage, (says Scarpa) is
situated so deeply  in  the bend of the
thigh, that it is  difficult, even in the
thinnest persons, to feel its neck, and in
examining is circumference with the ex-
tremity of the finger,  the  tendinous mar-
gin of the opening, through which the
parts  are  protruded,  can only be per-
ceived with  considerable  difficulty.  On
the  contrary, the inguinal herni.i,  h<,w-
ever small it  may be, is always less derp-
ly situated: it is about half.an inch above
 the  bend of the thigh. In carrying the
finger round its neck,  the  tendinous mar-
gin of the inguinal  ring a.', be easily felt
at its circumference; and at the posterior
part of the small tumour, the cord com-
 posed of the  spermatic vessels  is  distin-
 guishable.  When  the crural hernia has
 acquired a considerable size, its neck is
 always deeply situated in the bend ofthe
 thigh  ; but, its body and its fundus have
 a.'sttmed  an  oval  form, and their great
 diameter  is situated transversely in the
 bend of the thigh.   Whatever may be the
 bize of the inguinal herni;., it always pre-
 sents a tumour of a pyramidal  form, the
 ftase or fundus of which,  far from  being 
hekNia,
7*
 directed towards tlie  ilium, follows ex-
 actly the direction of the spermatic cord,
 and descends directly into  tlie scrotum.
 It may also be added, tliat, besides the
 symptoms, common to all hernial swell-
 ings,  the  crural  hernia,  when it- has
 attained  a certain size,  presents  some
 others, which are peculiar to it, such as
 a  sense of stupor  and heaviness in the
 thigh, and oedema  of the leg, and  even,
 of die foot of tlie same side.
   " In women, however, it is less easy to
 distinguish the  crural hernia from the
jnguinal.  In  fact, the absence  of the
 spermatic cord,  and the nearer situation
 of the ring to  the crural arch, may easily
 occasion a mistake.  Sometimes,  a wo-
 man  may even  be supposed to  have a
 double crural hernia of the same  side,
 whilst, of these two  distinct, though
 neighbouring  hernix, one may be ingui-
 nal, and the other crural. Arnaud  (Mem.
 de Chir.  Tom. 2, p. 605.)   relates an  in-
 stance of  such  a  mistake."  (Scarpa,
 Traite des Hernies, p. 207—208.)
   This interesting writer  takes occasion
 to observe further, upon this part of the
 subject, that  the portion  of the inferior
 pillar  of the abdominal ring, which sepa-
 rates this opening from the internal and
 inferior angle  of the  crural  arch,  is so
 slender in  women, that it is sometimes
 hard to distinguish the crural from the
 inguinal hernia,  which is not the case in
 male patients.
   Until very lately, the stricture,.in  cases
 of femoral hernia, was atways supposed
 to be  produced  by tlie lower border of
 the external oblique muscle, or, as it is
 termed,  Poupart s ligament.  A  total
 change of surgical opinion on  this sub-
ject, has, however, latterly taken place, in
 consequence of the accurate observations
 first made  in  1768, by Gimbernat, sur-
 geon to tlie king of Spain.  " In tlie cru-
 ral hernia, (says he) the aperture through
 which tlie parts  issue,  is  nut formed  by
 two bands, (as in the inguinal hernia) but
 it is a foramen almost round, proceeding
 from  the  internal  margin of the crural
arch  (Poupart's ligament,)  near  its in-
sertions into the  branch of the os pubis,
 between this bone and the iliac vein ;  so
that,  in this liernia, the branch of the os
pubis is situated more internally than the
intestine, and  a  little behind; the  vein,
externally,  and behind;  and the internal
border of the arch, before.  Now  it is
this border which always forms the stran-
gulation."  (See A new .Method of Ope-
rating for the Femoral  Hernia, by  Don
Antonio de Gimbernat, p. 6. Trans, by Bed-
does.)
  Mr. Hey, who attempted  to describe
some anatomical circumsunces, relative
 to the femoral hernia, and wrote subse-
 quently to Gimbernat, has certainly rather
 obscured, than thrown any light upon this
 part of the subject.   The inconsistencies
 and perplexities of his description, nave
 been clearly explained by M. Lawrence,
 to whose treatise I shall refer the reader.
 The latter gentleman makes the ligament
 described by Gimbemat,  perfectly intelli-
 gible, in a few  words:  when Poupart's
 ligament approaches the pubes, he states
 that it  becomes suddenly broader; that
 it is fixed by this broad portion, along
 the whole length of the angle and crista
 of the bubes; that it has a rounded and
 strong anterior  edge,  a  thin and sharp
 posterior margin;  and that the former of
 these is nearer to the surface, while the
 latter  is  comparatively  deeply  seated.
 The breadth of this part varies,  in  dif-
 ferent subjects: it is generally from three
 quarters of an inch to an inch.  Some-
 times, as Gimbernat has  stated, it mea-
 sures more than an inch.  Dr. Monro has
 observed, than it is  broader  in the male
 than in the female subject;  and, from
 this structure, he explains  in  part the
 more rare occurrence of this rupture in
 the male."  (P. 220.)
  The great utility of knowing, that it is
 this part, which produces the strangula>
 tion,  in cases of femoral hernia, is im-
 mense ; for  we then know, that  cutting
 the lower and outer border of the exter-
 nal oblique muscle, (in other words, Pou-
 part's ligament) is quite erroneous. This
 proceeding is the more to be  reprobated,
 because the lower pillar ofthe abdominal
 ring, in  both sexes, will be divided by di-
 recting  the incision  upward, or upward
 and inward; and thus the abdominal and
 crural rings, are made into one common
 aperture, large enough to  make the future
 occurrence of hernia very likely to bap-
 pen.  In the male,  also, there is consider-
 able danger of the spermatic  cord being
 cut.  Cutting  Poupart's ligament  ob-
 liquely outwards,  is attended with still
 more danger; for the epigastric artery
 will be  infallibly divided at its  origin.
With all  these  hazards, the cutting of
Poupart's ligament is quite useless, unless
the incision be carried on to the internal
edge ofthe crural arch.- (Gimbernat, p. 16.)
  Mr. B.  Bell, has the  merit of having
proposed the safest plan  of cutting Pou-
part's  ligament,  before  surgeons were
 aware of the part which really  formed
 the  strangulation :  he  introduced  his
 finger below Poupart's ligament, between
 the ligament and the intestine, (an  evi-
 dent proof,  says Gimbernat,  very truly,
 that there was no strangulation there;)
 he  then made a very superficial  incision
 from  above downwards, into the, thickest 
70
HERNIA.
 part of the ligament to its lower edge;
 and,  without cutting quite through  it,
 he 'continued   his  incision  about   an
 inch.  He rested the back of the scalpel
 upon his  finger, which served as a guide
 to the instrument, and, at the same time,
 as a defence to the intestine.  The  in-
 cision, however,  having been  continued
 for  an inch,  would,  as  Gimbernat  re-
 marks, inevitably cut the internal edge of
 the  crural arch.  Now, cutting this,  only
 for a  few lines, gives sufficient room for
 the easy reduction of the parts,  and there
 is no necessity  to touch the ligament,  as
 it  never  occasions  the strangulation.—
 (Gimbernat, p. 27.)
   The ihacus internus muscle is covered
 by a thin  fascia, called by  Mr. A. Cooper,
fascia iliaca. This is closely connected with
 the tendon of the psoas parvus, and is  in-
 serted into the posterior edge of Poupart's
 ligament, as far as where  the crural ves-
 sels pass  under this part.  It is  this fascia
 which prevents any protrusion of the vis-
 cera, on t he outside  of these vessels  But
 between the iliac vein, the thin posterior,
 deep-seated,  edge of Poupart's  ligament,
 and the os pubis, a space exists,  at which
 the  femoral  hernia makes its descent.
 Sometimes, at  this  point is situated a
 lymphatic gland; sometimes only cellular
 substance.
   The fascia lata  is not inserted into the
 w hole length of Poupart's ligament;  that
 is, not nearer the pubes than the femoral
 vessels.   Here  it is  continued  over the
 pectineus muscle;  consequently has  no
 connexion with the thin edge ofthe crural
 arch, nor with Potipart's ligament oppo-
 site the space, left between the vein and
 that thin  margin.  (Lawrence,p. 226)
   Where  the insertion of the fascia lata
 into Poupart's ligament ends,   it forms
 what  Mr. Burns of Glasgow  calls  the
falciform process, the upper part of which
 is attached to the above ligament, while
 the  lower  proceeds further  down the
 thigh.  Its  convexity  faces the pubes.
 This anatomical connexion is  one  chief
 cause,  why extending the  thigh,  and
 rotating it outward,  should make the cru-
 ral arch tense.
   Gimbernat named  the place where the
 femoral hernia protrudes tlie crural; Hey,
 the femoral ring.
   The hernia,  being situated in front  of
 the-pectineus, must  of course be exterior
 to the fascia lata.   In  my opinion,  sur-
 geons  are very much indebted to  Mr.
 Lawrence for his able explanation of this
 fact.   As for myself, I am candid enough
 to own that, until 1 read  his  clear and
 eoncisc account  of  the anatomy of the
 crural  hernia,   1 could never  reap any
 accurate  notions, concerning the relative
 situations* of the hernial sao and fascia of
 the thigh,  from other  more prolix works.
 This gentleman reminds us,  however,
 that  the particular crural  hernia,  con-
 tained in the sheath of the femoral  ves-
 sels,  lies  under the fascia;  p. 230.   Mr.
 Lawrence describes, that, " the falciform
 process ofthe fascia lata,  passes along the
 upper and outer part of the tumour.  Tlie
 iliac  vein  is placed on the outer  side of
 the neck ofthe sac; the pubes is directly
 behind  it; and the upper and inner parts
 are bounded by the thin posterior edge of
 Poupart's ligament."  The falciform pro-
 cess seems to have some inferior share in
 producing the strangidation;  the chief
 part  of which is formed, as  Gimbernat
 first  pointed  out,  by  the thin posterior
 edge of tlie crural arch.
   The sac  of the  femoral liernia is  ex-
 ceedingly narrow at its neck;  and, where
 its body begins, it becomes expanded  in a
 globular form : the sac of the bubonocele
 is generally of an  oblong shape.  The
 body of the sac of the  femoral  hernia,
 makes a right angle with the  neck, by
 being thrown jbrward and upward, a  cir-
 cumstance very necessary  to be known in
 trying to reduce the parts by the taxis.
   The  6ac  of the  femoral hernia is co-
 vered by a kind of membranous  expan-
 sion,  consisting of condensed cellular sub-
 stance,  and named  by Mr. A. Cooper,  the
fascia propria.  According to this gentle-
 man, another covering extends over the
 swelling,  from the superficial  fascia of
 the bend  of the thigh.   It is of infinite
 use to remember these circumstances in
 operating, lest one should think the herni-
 al sac divided, when it is  not so.
   All late  writers on hernia,  have re-
 ma! ked how  very  small  the aperture is,
 through which the viscera protrude in
 the femoral rupture;  how much greater
 the   constriction  generally is, than in
 the bubonocele; consequently, how much
 more rapid the symptoms  are ;  how much
 less  frequently  the taxis succeeds;  and
 how  much more dangerous delay proves
 (See  A. Cooper, Hey, Lawrence, 6}c.)
   Though the crural ring  is almost always
 very  small, yet in a few instances, in which
 the tum<mr is very large,  and of long
 standing,  it becomes very capacious, just
 as the  opening often  becomes, through
 which the inguinal  hernia protrudes.  Dr.
 Thomson,  of Edinburgh,  Mr.  Hey,  and
 Mr. Lawrence, have related examples of
 this kind.
   The  remarks already  made, concern-
 ing the treatment  of  hernia,  before  hav-
 ing recourse  to  the knife, are all appli-
 cable to the present case,  and we need ntt
 repeat them.  In attempting to reduce the
 femoral hernia by tlie taxis, tlie surgeon 
HERNIA.
77
should recollect, however, that relaxing
Poupart's ligament, and the femoral fas-
cia, is of tlie highest consequence. Hence,
the thigh should be bent, and rolled in-
wards.  The pressure ought  also to be
first made downwards and backwards,  in
order to push the  swelling off Poupart's
ligament; and afierwards, the parts should
be propelled upwards, so as to try to get
them through the crural ring.

OPERATION FOR  THE FEMORAL,  OR CRURAL
                HERNIA.

  Mr.  A. Cooper says,  " the incision  of
the integuments is to be begun an inch and
a half above the crural arch, in a line
with the middle of the tumour, and ex-
tended downwards to the center of the
tumour below the arch.  A second  inci-
sion,  nearly  at right  angles  with  the
other, is next made, beginning from the
middle of the inner side of the tumour,
and extending it across  to the outer *side,
sc that tlie  form of this double  incision
will be that of the letter T reversed."  The
angular flaps are,  of course, to be  next
dissected off, and reflected.
  T1, t making of two incisions, however,
is not deemed necessary by the majority
of surgeons; and, in all  the  numerous
operations I  have seen performed by the
surgeons of St. Bartholomew's Hospital,
during a space of nearly fifteen years,  1
never knew them  have any  occasion  to
make any transverse  wound.   The  divi-
sion of the  skin should begin about an
inch above the crural ring,  and be  con-
tinued obliquely  downwards  and  out-
wards.  In tliis  manner, we  cut exactly
over the place,  where the incision of the
stricture should be made.
  " The first  incision  (says  Mr.  A.
Cooper)  exposes  the  superficial  fascia,
which is given off' by the external oblique
muscle,  and which  covers  the anterior
part of tlie hernial sac ; but,  if the patient
is thin, and the hernia ha* not been  long
formed, this fascia escapes observation,
as it is thrn slight and delicate, and ad-
heres closely to the inner side of the
skin.  When this  fascia is  divided, tlie
tumour is  so far  exposed,  that the cir-
cumscribed  form of the hernia may be
distinctly seen; and  a  person,  not  well
acquainted with the anatomy ofthe parts,
would read ly suppose that the sac itself
was now  laid  bare.  This, however,  is
not the case, for it is still enveloped  by a
membrane, which  is the fascia, that the
hernial sac pushes before it, as it passes
through  the  inner  side  of the  crural
sheath.   This membrane,  the fascia pro-
pria, is to be next divided longitudinally
from  the  neck to the fundus of the sac;
and  if  the subject is fat,  an  adipose
membrane lies between it  and the sac,
from which it may be distinguished, by
seeing the  cellular membrane  passing
from its inner side to the surface of the
sac.
  " This  is, in my opinion,  the  most
difficult part of the operation;  for the
fascia propria is  very liable to be  mis-
taken for the sac itself; so that,  when
it is divided, it is  supposed that the sac
is exposed, and the intestine is laid  bare:
following  upon this idea, the stricture is
divided in the outer part of the sac, and
the intestine, still strangulated, is  push-
ed, with the unopened sae, into the cavity
of the abdomen.
  " The hernial sac being exposed, is to
be next opened; ajid,  to divide it with
safety, it  is best to pinch up a small part
of it hetween the finger and thumb; to
move  the thumb  upon the finger,  by
which'the intestine is  distinctly felt, and
may be separated  from the inner side of
the sac ;  and then to cut into the sac, by
placing the blade  of  the knife horizon-
tally. Into this opening, a director should
be passed, and the sac opened from its
fundus to  the crural sheath."  (A. Cooper
on Crural and Umbilical Hernia.)
  Sometimes the contents of the hernia,
thus exposed, admit  of being  returned,
without tlie further use  ofthe knife. When
this  object, however,  cannot be readily
done, the protruded parts should  never
suffer  injury  in  repeating  manual  at-
tempts ; and it is safest to divide the stric-
ture at once.
  Gimbernat's method of dividing the
stricture,  in cases of femoral herniae, may
be regarded as the most effectual, and
safest.   " Introduce, along  the  internal
side  of the intestine,  a cannulated or
grooved sound, with a blunt end, and a
channel of sufficient depth.  This is to
be directed obliquely inwards, till it enter
the crural ring, which  will  be  known by
the increased resistance;  as also  when
its point rests upon tlie branch of tlie os
pubis.  Then suspend  the introduction;
and  keeping the  sound (with  your left
hand, if you are  operating on  the right
side, and  v. v.)  firmly resting  upon the
branch of the os pubis, so \"*r its back
shall  be  turned  towards  the  intestine,
and its canal to the symphysis pubis, in-
troduce gently with  your  other  hand,
into  the groove of the sound, a bistoury,
with a narrow blade and blunt end,  till
it enter the ring.  Its entry will  be known,
as before, by a little increase of resibtance.
C.iutiously "press  the bistoury to the end
of the canal; and employing  your two
hands at  once,  carry  both  instruments
close along the branch  to the body of the 
78                                HERNIA.
 pubis,  drawing them  out at  tlie same
 tune.   By this easy operation, you will
 divide  the internal edge of the crural
 arch at its extremity, and within four or
 five lines of its duplicative; tiie remain-
 der continuing firmly attached, by the  in-
 ferior band, or pillar,  of which it is  the
 continuati^i.   This simple  incision  be-
 ing thus made, without the smallest dan-
 ger,  the internal  border of  the  arch,
 which  forms  the  strangulation,  will  be
 considerably relaxed,  and the parts will
 be reduced with the greatest ease." (Gim-
 bernat,  p. 45,  46.)
   Mr. A. Cooper  recommends the stric-
 ture to be divided "obliquely  inwards
 and upwards, at right angles to  the cru-
 ral arch."
   After advising us to open the  sac of a
 femoral hernia with particular  care,  on
 account of its being much thinner than
 that of a bubonocele,  and (as might  be
 added)  on account of  its seldom  contain-
 ing any fluid,  and  often having no omen-
 tum in it  covering the  intestine,  Mr.
 Hey remarks,  " The stricture made upon
 the  prolapsed  parts is very great, as I
 have already observed; but if tlie tip  of
 the finger  can be  introduced within the
 femoral  ring,  to  guide the bubonocele
 knife, a small incision (for  the  ring  is
 narrow) will be sufficient to set the parts
 at liberty.  If the tip of tlie finger cannot
 be  introduced  at the proper place, a di-
 rector with a deep groove must be used
 instead  of the finger;  but I prefer the
 latter.   The finger, or director, should
 not be  introduced  very near the great
 vessels ; but on that side  of the intestine
 or omentum which is nearest to the sym-
 physis   of  the ossa pubis.  The incision
may then be made directly  upwards.  The
surgeon  must take especial care to  in-
troduce his finger or director within that
 part where he finds the stricture to be the
greatest, which, in this species of hernia,
is  the  most interior part of the wound."
 (P. 155.)
  Gimbernat's mode is preferable to Mr.
 Hey's,  because, were the  operation done
on a male, cutting  directly upward would
endanger the spermatic cord.
  Mr.  L»*rence has noticed,  "an inci-
sion ofthe most interior part of tlie stric-
ture is  free from  all danger, in  the or-
dinary  course of the vessels.  But that
variety, in which  the  obturator artery,
arising from the epigastric, runs along the
inner margin of the sac, seems to preclude
us from cutting  even  in this direction.
A mode of operating has been lately pro-
posed,  (Edinb. Med. and Surg. Journal,
 Vol. 2, p. 205.) with a view of avoiding this
danger.  Wo  are  directed  to  make  an
 incision through the aponeurosis of the
 external oblique muscle, just above the
 crural  arch, and  in  a  direction parallel
 to that part: to introduce a director under
 the stricture from this opening, and to
 divide the tendon to the requisite extent,
 by  means of a curved knife, passed along
 the groove."  (Treatise on the Hernia, p.
 247.)   For reasons which  Mr. Lawrence
 states, tliis plan is certainly not altogether
 eligible, and, upon the whole, Gimbernat's
 method of cutting  the stricture is the
 safest.   Monro computes,  that the obtu-
 rator artery may arise  from the epigas-
 tric, once in twenty-five or thirty subjects.
 But, allowing that it   originates  more
 frequently, it then does not always de-
 viate from its usual course along the out-
 side  of the sac.  Mr.  A  Cooper says:
 " in all  cases, which I have myself dis-
 sected,  where this variety  existed  with
 crural hernia, the obturator has passed
 into the pelvis, on tlie  outer side of the
 neck of the sac, entirely out of the reach
 of any danger of the knife."  ( On Crural
 Hernia, p. 21.)  Mr. Lawrence concludes,
 that the comparative number of instances,
 in which it is found on  the opposite side,
 cannot be more  than one out of eiglit, or
 ten, and consequently  it would  only be
 liable to be wounded once in eighty or one
 hundred operations.   (P. 252.)•
  It is observed  by  professor  Scarpa,
 that " the round ligament  of the uterus,
 in passing through the abdominal muscles,
 follows precisely the same track as the
 spermatic  cord.  It is  equally  situated
 behind  Poupart's ligament, with  the dif-
 ference,  that it  does not become so dis-
 tinct from the internal  extremity of this
 ligament, as the spermatic cord does, be-
 cause it has not so far to run, in order to get
 from that ligament to the  inguinal ring,
 the latter opening being situated lower in
 the female,  than the male  subject..  The
 round ligament, like the spermatic cord,
 also crosses the  epigastric  artery, before
 reaching the inguinal ring.  And as the
 crural hernia always begins at  the in-
 ternal and inferior angle of the  arch  of
 this name,  as well in  the  male as the
 female, it follows,  that  in the two sexe3,
 the  epigastric artery remains in its na-
 tural situation, and invariably  corres-
 ponds to the external side of the  neck  of
 the crural hernia;  whilst  tlie spermatic
 cord, in man, and the  rour.d ligament,
 in women, pass over the extremity of the
 front of the neck of the hernial  sac.  In
 the  operation for  the  crural hernia,  in
 females, the incision of the  neck of the
 hernial  sac,  and crural arch, when di-
rected upward  towards the  linea alba,
 cannot wound the epigastric artery, which
 it is of the most consequence to avoid ; 
HERNIA.   .
79'
but it  always divides,  either  totally or
partially, the round ligament  of the ute-
rus,  Which cannot lead to any  dangerous
hemorrhage; for,  out  of the period of
pregnancy, the arteries  of the round li-
gament are.very small; they are  almost
obliterated in women advanced in years;
and  in general  they are quite capillary
in the  extremity of the  ligament adjoin-
ing  the ring.  Hence, it cannot be sur-
prising, that  so many crural hernia: have
been successfully  operated upon  in wo-
men, by cutting the hernial sac and cru-
ral arch  directly  upward, while  not a
single  instance can be cited  of such an
incision being made in  man without any
ill consequence, altliough in  both sexes,
the  epigastric artery  may  have  been
avoided  in operating  by this process."
(Scarpa, Traite, des Hernies p. 240.)
   In operating for the crural hernia in
males, Scarpa recommends us to follow
a method which he calls new, but which
in fact, is the same  as that advised by
Gimbernat.   " I have found (says Scarpa)
that, in man, the neck of the hernial sac
may be divided without danger, by giving
to the  incision a  direction exactly con-
trary to that, which is practised, in the
female subject.  After having opened the
hernial sac, it is to  be  drawn outward by
one of its sides  sufficiently to allow the
introduction  of a small director between
its neck and  the  strangulated intestine,
the groove of the  instrument being turned
downwards towards the internal and inferior
angle ofthe crural arch.  A probe-pointed
bistoury, the edge of which is also to be di-
rected  downwards  towards  the  point of in-
sertion of Poupart's ligament to the pubes,
is to be pushed along the groove.  By this
means, the neck ofthe hernial sac will be di-
vided its whole length, at its internal and in-
ferior side, and Poupart's ligament will be
cut cose to its attachment to the top of tlie os
pubis.   The epigastric artery  will be cer-
tainly  avoided,  because it  lies upon the
opposite side of tlie hernial sac.  As for
the spermatic cord, I have demonstrated,
that it is situated  on the forepart of the
neck of the hernial sac ; consequently, it
cannot be touched by  an incision made
from above  downwards,. whilst it  is'con-
stantly cut in the ordinary method, since
the knife is carried from below upwards.
In the first case, this part may be the more
easily avoided, as it lies at some distance
from the  internal  and  inferior angle of
the  crural  arch.   In  fact, it is at  this
place,  that it quits,  as we   have  seen,
the  edge of  Poupart's  ligament, in order
to   ascend   towards the   inguinal ring.
The incision, that I propose (says Scarpa)
not  only  has the advantage  of slitting
open  the neck ofthe hernial sac its whole
length,  it also divides  a part of tlie  in-
sertion  of Poupart's  ligament into the
upper part of the os pubis, a thing, that
greatly  contributes  to relax the crural
arch, and facilitate  the reduction of the
viscera ; of tlyjse, at least,  which are not
adherent to the sac."  (Scarpa,  Op. cit.
p. 235.)
  Altliough this accurate anatomist and
surgeon appears to be quite unacquainted
with many of the late valuable publica-
tions  on hernia, which have  made  their
appearance in this country, it is curious
to find,  both  in  his account  of the  in-
guinal and crural hernia, how strongly his
doctrines and observations tend  to con-
firm every thing  that  has  recently been
insisted upon  in modern works, respecting
the place where the bubonocele first pro-
trudes,  its  passing  through  a sort of
canal before it comes out ofthe abdominal
ring,  the advantage of cutting  in  the
crural hernia  the  internal and  inferior
angle of Poupart's ligament,  or, in other
terms,  that part of  the ligament, which
was first  particularly  pointed  out  by
Gimbernat, as causing the principal pan
of the strangulation, and about which so
much has  been said by Mr.  A. Cooper,
Mr. Hey, &c.                   •

          C0NHF.N1TAL REHNIA.

  Before the beginning   of  the  sixth
month  of the foetal state, the testicle  is
situated near the  kidney, where it re-
ceives a covering from the peritonaeum,
just like the  other abdominal  viscera.
Between  the beginning  of  the  sixth
month,  and end of the seventh, the  testi-
cle has  either descended  as  low as just
above the abdominal ring, or else  is pass-
ing through it, or just below it. ( Wrisberg.
Comm. Reg. Societ. Gotting. 1578.)
  When the  testicle passes through the
abdominal ring into the scrotum, it carries
before it a production of the peritonaeum,
which afterwards constitutes the tunica
vaginalis;  while  that  peritoneal invest-
ment, which  was given to the testicle  in
the loins, is closely adherent to this body,
and forms what  is* named  the tunica al-
buginea.
  After the  descent of the testicle into
the scrotum,  the communication between
the cavity of  the tunica vaginalis and that
of the  abdomen,  commonly becomes ob.
literated, which latter event is  usually
effected before  birth, sometimes  not till
afterwards, and in a  few subjects, even as
late as the  adult state.
   In the  pongenital  hernia,  the  pro-
trtaled viscera are situated in the tunica 
80  '
HGRN1.V.
 vaginalis, In contact with the testicle;
 having  descended into  this position  be-
 fore the closure of the communication
 with the abdomen.  Of course, the tunica
 vaginalis  itself is the hernial  sac.  The
 nature of this  case was not understood,
 before it was  elucidated  by  Haller in
 1755, and the two Hunters in 1762 and
 1764.  (See Hunter's  Med.  Comment. :
 Holler's Opuscula Patholog. and Opera Mi-
 nora,  Tom. 3.)  Before that period, sur-
 geons imputed the circumstance of the
 contents of the hernia and testicle being in
 contact, to the former parts having made
 their way, by laceration, through the tu-
 nica vaginalis,  from the ordinary hernial
 sac  of a bubonocele. The old surgeons,
 indeed, frequently cite this instance,  in
 proof of their doctrine, that some herniae
 were attended with  a laceration  of the
 peritonaeum.  (See Sharp's Enquiry.')
   From  the term  congenital,  we might
 suppose, that this hernia always existed
 at the time of birth. The protrusion, how-
 ever, seldom occurs till after this period,
 on  the operation  of the usual exciting
 causes  of herniae in general.   The con-
 genital hernia  does not usually happen
 till some  months after birth ; in some in-
 stances, not till a late period.  Mr. Hey
 relates a«case,  in which a  hernia conge-
 nita was first  formed in  a young  man,
 aged sixteen, whose right testis had, a
 little while before the attack of the dis-
 ease; descended  into the  scrotum.  It
 seems probable, that in the cases of lier-
 nia congenita, which actually take place
 when the testicle descends into the scro-
 tum  before birth,  the  event may com-
 monly be referred to the testicle having
 contracted an adhesion to  a piece of in-
 testine, or of the omentum, in its passage
 to the ring.   Wrisberg found one testicle,
 which had not passed the ring, adhering,
 by means of a  few slender  filaments,  to
 the omentum, just above this aperture,  in
 an infant,  that  died a few  hours after
 birth.
  Excepting the impossibility of feeling
 the testicle in  hernia congenita, as we
 can in most cases of bubonocele, (which
 criterion Mr. Pott should have mention-
 ed,) the  following accent  is very  excel-
 lent.  ** The appearance of a  hernia  in
 very  early infancy,  will always make  it
 probable "that it  is of this kind ;  but,  in
 an adult, there is no reason  for supposing
 his rupture  to be of this sort, but his
 having been afflicted with  it  from his
 infancy ; there  is no external  mark, or
 character, whereby it can be certainly dis-
tinguished from one contained in a com-
 mon hernial sac ; neither would it be of
 any material use in practice, if there was,
   " When  returnable, it ought,  like all
 other kinds of ruptures, to be reduced,
 and constantly kept up by a proper band-
 age ;  and  when  attended  with  symp-
 toms  of stricture, it  requires  the same
 chirurgie assistance as the common hernia
   " In very young  children,  there are
 some  circumstances, relative  to this  kind
 of rupture, which are very  well worth
 attending to, as they may prove  of  very
 material consequence to the patient.
   " A piece  of intestine,  or omentum,
 may get pretty low down in the sac, while
 the testicle is* still in the  groin, or even
 within the abdomen ; both which I have
 seen.  In this  case, the application  of a
 truss/ would be highly  improper ; for in
 the latter, it might prevent the descent
 ofthe testicle from the belly into the scro-
 tum ;  in the former,  it must necessarily
 bruise and injure it, give a great deal of
 unnecessary pain,  and  can prove of no
 real use.  Such bandage, therefore, ought
 never  to be applied  on a rupture in an
 infant, unless the  testicle  can be fairly
 felt in the  scrotum, after the gut or  caul
 is replaced ; and when it can  be so folt, a
 truss can never be put on too soon.
   " As this kind of rupture is subject to
 stricture, with  all  its consequences, as
 much  as that which is contained in * com-
 mon hernial sac, and therefore liable to
 stand in need of the chirurgie  operation;
 it may be very well worth  an operator's
 while to know, that an old rupture, which
 was originally  congenital,  is subject  to a
 stricture made  by the  sac itself, inde
 pendent of the abdominal tendon, as well
 as to that made by the said tendon.
   " Whether this be owing to the weight
 of the testicle  at  the bottom of the  sac,
 and the endeavours which  nature makes
 to close the upper part of the tunica vagi-
 nalis, or to what other  cause, I will not
 pretend to say, but the fact I have seve-
 ral times noticed, both in the dead and in
 the  living.   I have  seen such stricture
 made by the sac of one of these herniae,
 as produced all those bad symptoms which
 render the  operation necessary; and  I
 have  met with two  different  strictures,
 at near an inch distance from each other,
 in the body of a dead boy, about four-
teen, one of which begirt the intestine so
tight, that I could not disengage it with-
out dividing the sac.
  " In this  kind of hernia I  have also
more frequently found  connexions  and
adhesions of the.parts to each other, than
in the common one ; but there is one kind
of connexion sometimes met with in  the
congenital hernia,  which can never be
found in that which is  a  common hernial
sac, and which may  require all the dex- 
HERNIA.                                 81
 terity of an operator to set free,-  I mean
 that  of the  intestine with  the  testicle,
 from which 1 have more than once expe-
 rienced a good deal of trouble.
   " When a common hernial sac has been
 laid open, and the intestine and omentum
 have been  replaced, there can be nothing
 left in it which can require particular re-
 gard from  the surgeon;  but by the divi-
 sion of the sac of a congenital hernia, the
 testicle  is laid  bare, and after  the parts
 composing the hernia have been reduced,
 will require great regard and tenderness,
 in all the future dressings, as it is  a part
 very  irritable,  and  very susceptible of
 pain, inflammation, &c.
   " If a large quantity of fluid should be
 collected in the sac of a congenital heniia,
 and, by adhesions and connexions of the
 parts within, the entrance into it from the
 abdomen should be totally closed, (a case
 which I have twice seen) the tightness of
 the tumour, the difficulty of distinguishing
 the testicle, and the  fluctuation of the
 fluid, may  occasion it to be mistaken for
 a common hydrocele; and if without at-
 tending to other circumstances, but trust-
 ing merely to the feel and look of the scro-
 tum, a puncture be hastily made, it may
 create a great deal of trouble, and possi-
 bly do fatal mischief.
   "By what has fallen within my obser-
 vation, I am inclined  to believe  that the
 sac of a congenital hernia is  very seldom,
 if ever, distended to the degree which a
 common  hernial sac  often  is:  it also,
 from being less dilated,  and rather mos>
 confined by the upper part of the sperma-
 tic process, generally preserves a pyriform
 kind of figure, and, for the same reason,
 is also generally thinner, and will there-
 fore require more attention and dexterity
 in an operator when he is to open it.  To
 which I believe I may add, that common
 ruptures, or those in a common sac, are
generally gradually formed, that is, they
 are first inguinal, and by degrees become
 scrotal; but the congenital are seldom, if
 ever, remembered by the patient to have
 been in the grout only."   (Pott  on Rup-
 tures, Vol. 2.)
  The reader  must  not conclude, how-
ever, from the above  account, that every
rupture in  children is a congenital one.
Mr. Lawrence has related a case of stran-
gulated bubonocele,  which  took  place
in an infant only fourteen  months  old.
(P. 31.)
  The common inguinal hernia, which first
protrudes at the  inner opening of the in-
guinal canal, and which has the epigas-
tric artery on the inner  side  of its  neck,
has been  named  by Hessclbaeh external,
    Vol. II.
 while the less common instance, in  which
 the viscera  pierce  directly through the
 aponeuroses of the  transverse and inter-
 nal oblique muscles, and pass  directly
 out of the  abdominal  ring,  leaving the
 epigastric artery on  tiie outer side  of the
 neck of the  sac, is  distinguished by the
 epithet internal. (Anatomisch. Chirurg. Ab-
 handlung.  uber den Ursprung  der Leisten-
 bruch.)  " The inguinal congenital  hernia
 (says Scarpa) cannot be  divided  into ex-
 ternal and internal;  it is evident, that  it
 must always be external, since the neck
 of the tunica vaginalis  invariably  corre-
 sponds to  the point at which the  sperma-
 tic cord passes  under the margin of the
 transverse muscle.  As for other circum-
 stances, the tunica vaginalis  lies  in its
 whole course in the same manner as the
 sac  of a  common inguinal  hernia .- like
 this, it passes completely through the in-
 guinal canal from one end to the  other,
 resting upon the  anterior  suiface of the
 spermatic  cord.  Consequently, it passes
 between the separation  of  the  inferior
 fibres  of the obliquus internus,  and the
 principal Origin  of the cremaster muscle:
 (See Wrisberg. sylog. comment, anat. p. 23.)
 After coming out ofthe ring, being always
 united to the spermatic cord, it is enclos-
 ed in the muscular and aponeurotic sheath
 of the cremaster  muscle,  which accom-
 panies it to  the bottom  of the scrotum.
 Since  the  tunica vaginalis, including the
 displaced   viscera,  enters  the inguinal
 canal on the outside ofthe point, at which
 the  spermatic cord crosses tf^fepigastric
 artery, it  is manifest, that, s^nt follows
 exactly tlie direction of this cord, it must
 also cross  the artery, and remove  it  from
 the outer  to  the inner side of the  ring,
 according to  the mechanism already ex-
 plained in  speaking of the common in-
 guinal hernia.  Hence, the displacement
 of the epigastric artery  constantly hap-
 pens in the inguinal congenital, just  as it
 does in the  ordinary external inguinal
 hernia.
  " But, if these two species of inguinal
herniae have some analogy to  each other,
 in regard to  the parts which constitute
 them, yet,  they present some remarkable
differences.  1.  The common  inguinal
 liernia,  whether  internal,  or external,
 when it extends into the scrotum, cannot
 descend beyond the point at which flie
spermatic vessels enter the testicle. There
the cellular  substance of the spermatic
cord terminates.   There  the hernial sac
must  unavoidably terminate.  On  the
contrary, in  the congenital  hernia, the
viscera may descend lower, than the testi-
cle,  with  which they are in  immediate
  L 
82                                HERNIA.
contact; and, at length, they even occupy
the situation of this organ, which is then
pushed upward and backward.  2.  In
the case  of a congenital  hernia, the de-
scent of the viscera from the groin to the
scrotum commonly takes place  in a very
short time, and in  some  measure preci-
pitately :  it is  much  slower and  more
gradual in the ordinary  inguinal hernia.
The  reason  of this difference  is very
plain.  In the  first case, the descent of
the testicle, and the formation of the tu-
nica vaginalis, have opened and prepared
tlie route, which the viscera must follow
in forming  a protrusion; while, in the
second, the hernial  sac  cannot descend
into the scrotum, but by gradually elon-
gating the layers of the cellular substance,
which joins it to the surrounding parts.
This fact  is  so  generally  known, that
experienced  practitioners  consider  the
promptitude, with which the viscera have
descended from the groin to the bottom
of the scrotum, as a characteristic sign,
of a scrotal congenital hernia."   (Scarpa,
Traite des Hermes, p. 73,  &c.)
  If circumstances will admit of a truss
being applied and worn, in cases of con-
genital hernia,  in young subjects, there
will be a considerable chance of a radical
cure being effected, in consequence of the
natural propensity of the opening between
the abdomen  and tunica  vaginalis to be-
come closed.
  The only  material difference in the
operation, from that for a bubonocele, is,
that the sdfeon has to lay  open the tu-
nica vagimM^ instead of a common her-
nial sac.   The stricture is to be  divided
on the same principle as that  of an in-
guinal hernia,  and  much  in  the same
manner.   The parts having been reduced,
the edges of the wound are to  be imme-
diately brought together, and retained so
by  means of  one  or two  sutures, and
sticking plaster, which is  much preferable
to the plan of applying the dressing to
the testicle and inside of the tunica vagi-
nalis, so as to heal tlie part by the granu-
lating process.
   A new species of hernia congenita has
lately been described, in which a com-
mon peritoneal hernial. sac,  containing
the viscera, is included in the tunica va-
ginalis.  It arises  from  the parts being
proxruded, alter  the communication be-
tween the abdomen and  tunica vaginalis
is closed, so that the peritonaeum is car-
ried down along with the intestine, and
form* a hernial sac, within the tunica va-
ginalis.  It is evident also, that such a
hernia can only be produced,  while the
original tunica vaginalis  remains, in the
form of a bag, as high as the abdominal
ring.  Operators should be  aware_ of the
possibility of having a sac to divide,  a£
ter laying open the tunica vaginalis.  (See
the accounts of this hernia in Hey's Prac-
tical  Observations, p. 221,  (Jc. and  A.
Cooper's Work o?i Inguinal Hernia, p. 59.)

   UMBILICAL HERNIA, OR EXOMPHALOS.

   "The exomphalos,  or  umbilical rup-
ture, (says Pott) is so called from its situ-
ation, and has (like other herniae) for  its
general contents,  a  portion of intestine
or omentum, or both.  In old umbilical
ruptures,  the  quantity of  omentum is
sometimes very great.
   " Mr. Ranby says, that  he found two
ells and half of intestine in one of these,
with about a tlurd part of the  stomach,
all adhering together.
   " Mr. Gay and  Mr. Nourse found the
liver in the sac of an  umbilical hernia;
and Bohnius says  that he did also.
   " But whatever are the contents, they
are originally contained in the sac, formed
by the protrusion  ofthe peritoneum.
   " In  recent  and small  ruptures, this
sac is very  visible; but in old, and large
ones, it. is broken through at the knot of
the navel, by the pressure and weight of
the contents, and is not always to be dis-
tinguished; which is the reason why it
has by some been  doubted  whether this
kind of rupture has a hernial sac or not.
   " Infants are very  subject to this dis-
ease, in a small degree, from the separa-
tion ofthe funiculus; but in general they
tffther get rid of it as they gather strength,
or are  easily cured by wearing a proper
bandage.  It is of still more consequence
to get this disorder cured in females, even
than in males, that its return, when they
are become adult,  and pregnant, may  be
prevented as   much as possible;  for  at
this time it often  happens, from the  too
great distention of the belly, or from un-
guarded motion when the parts are upon
the stretch.  During gestation, it is often
very troublesome, but  after delivery, if
the contents have contracted no adhesion,
they will often return, and may be kept in
their place by a proper bandage.
'   " If such bandage was always put  on
m time, and worn constantly, the disease
might in general be kept within moderate
bounds, and some ofthe very terrible con-
sequences Which often attend it might be
prevented.   The   woman  who  lias  the
smallest degree of it, and  who from her
age and situation has" reason to expect
children after  its  appearance, should  be
particularly careful to keep it restrained.
   " In some the entrance of the sac is
large,  and  the parts easily reducible;  iu
others they  are difficult, and in some ab- 
HERNIA.
83
 Dolutely irreducible.  Of the last kind
 many have been suspended for years in a
 proper bag,  and have given  little or no
 trouble.  They who are  afflicted with
 this  disorder, who are  advanced in lite,
 and in  whom  it is large, are  generally
 subject to colics,  diarrhoeas, and, if the
 intestinal canal be  at all obstructed, to
 very  troublesome  vomitings.  (Hence,
 patients are often supposed to labour un-
 der a stricture, when they really do not.)
 It  therefore behoves such to take great
 care to keep that tube  as clean  and free
 as possible, and neither to eat, or drink
 any thing likely to  make any disturbance
 in that part "  (Pott on Ruptures, Vol 2.)
   Authors, who have published since the
 time of this.celebrated surgeon, have not
 added much to the stock of information,
 which he has left,  relative to the exora-
 phalos.  The writings of Mr. A. Cooper,
 Scarpa, (Traite des Hernies, p. 327.) and
 of all the most accurate moderns, confirm
 the fact, described by Pott, that, in the
 umbilical rupture, there is a hernial sac,
 just  as in other  instances  of herniae.
 Every - one,  acquainted with anatomy,
 knows,  that  behind the opening in  the
 luiea alba  at the  umbilicus, the perito-
 neum is complete, and consequently must
 be protruded before the viscera,  in cases
 of exomphalos. In the only two cases,
 which Mr.  A. Cooper has seen of a defi-
 ciency of the sac, the membrane had been
 partially absorbed,  or lacerated, so as ,to
 allow the protrusion of its contents, and
 threaten, from  this  cause, a double stric-
 ture. Similar  appearances less  closely
 inspected, probably gave rise to  the opi-
 nion so  firmly  maintained  by Dionis, De
 la Faye, Garengeot, and J.  L.  Petit, that
 in the umbilical hernia, the peritoneum
 was always lacerated, and there was no
 hernial  sac.  It is  observed  by  Bichat,
 that the umbilicus is a kind of cicatrix,
 formed,  in consequence of  the  separa-
 tion of the funis, by the contraction of the
 parts with which it  was  continuous ; and
 that it only gradually acquires the degree
 of firmness which it has in the adult sub-
ject.  As it is  for  a long while weaker
than the rest of the abdominal parietes,
it oidy makes an inferior degree of resist-
ance to  the viscera; but this resistance
increases with  age;  and,  as the  cicatrix
now becomes stronger than the surround-
ing parts, it forms  a more impenetrable
barrier against any escape of  the  bowels.*
From these anatomical facts, the follow-
ing pathological inferences, confirmed by
experience, are deducible :—1.  That in-
fancy is more subject, than any other age,
to the umbilical hernia, strictly so called,
in which the parts protrude through the
navel.   2 That other periods of life are*
 more  subject  than  infancy to false um*
 bilical herniae or to  those which  arise in
 the  vicinity  of the  umbilicus.  ((Euvres
 Chirurgicales de Desault, par Bichat, Tom.
 2, p. 315.)
   Besides a  true hernial sac, the exom-
 phalos is also covered with a more super-
 ficial expansion, consisting of condensed
 cellular  substance.  In   operating,  we
 should always  cut,  however,  with great
 caution,  for, often the integuments and
 hernial sac,  in  front of the tumour, are
 inseparably adherent;  and sometimes,  in
 consequence of the pressure ofthe viscera,
 in large cases,  having  caused an  absorp-
 tion of part of the sac, they are even found
 adherent to the integuments.
   Pregnant" women, and dropsical  and
 corpulent subjects, are peculiarly liable
 to the exomphalos.  In  adults, there  is
 almost always omentum in the  sac  when
 there is  intestine.  The transverse arch
 of the colon is observed to be particularly
 often  contained  in  umbilical  herniae,
 though the small intestines are not unfre-
 quently protruded.   (Lawi-ence, 265.)
  In the true umbilical hernia, the stric-
ture  is made by the tendinous opening in
the linea  alba.  We shall next consider
the umbilical hernia in  the three particu-
lar forms in which it has been noticed  by
the latest writers.
     CONGENITAL UMBILICAL HERNIA


   Dr.  Hamilton has met with about two
 cases of this kind annually, for the space
 of seventeen years; and they strictly de-
 serve  the epithet  congenital, as they ap-
 pear at birth.  The funis ends in a sort
 of bag, containing  some of the viscera,
 which pass out  of the abdomen through
 an aperture in the situation of the navel.
 The swelling is not covered with skin, so
 that the contents of the  hernia  can  be
 seen through the thin distended covering
 of the  cord.  The cLsease is owing to a
 preternatural deficiency in the abdominal
 muscles, and the hope of cure must be re-
 gulated by the size of the malformation,
 and quantity of viscera protruded.
   The plans of cure proposed,  consist of
 the  employment of a  ligature, or of  a
 bandage.   The  latter  seems  preferable,
 and  was practised by Mr. Hey, as fol-
lows :  having reduced  the intestine,  he
 desired an assistant to hold the funis com-
 pressed sufficiently near the abdomen,  to
 keep the bowel from returning into the
 hernial sac.
   "  I  procured (says  he) some plaster
 spread upon  leatlier,  cut into circular
 pieces, and laid  upon  one another in a
 conical form.   This compress  I  placed 
84
HERNIA.
upon the navel, after I had  brought the
skin on each side of the aperture inio
contact, and had laid one of the  lips a
little over the  other.  I then  put  round
the child's abdomen, a linen belt; and
placed upon tiie inn el, a thick, circular,
quilted part,  formed  about two inches
from one extremity of tiv belt.
  "This bandage  kept the  intestine  se-
curely within the abdomen,  and was  re-
newed occasionally.  The funis was  se-
parated about a week after birth; and at
the expiration  of a  fortnight from that
time, the aperture at the navel was  so  far
contracted, that the crying of the  child,
When  the bandage  was removed, did not
cause the least protrusion.   I  thought it
proper, however, to continue  the use of
tlie bandage a little while longer. A small
substance, like fungous  flesh, projected,
after the funis had dropped off, about half
an inch from the bottom  of that depres-
sion which the navel  forms.   A dossil of
lint spread  with cerat. e  lapide calami-
nari, and assisted by  the pressure of the
bandage, brought on a complete cicatriza-
tion."   (P. 227)
  This gentleman has related another ex-
ample, in which the intestines were quite
uncovered, and inflamed, the sac having
burst  in delivery.   The parts were reduc-
ed ; but tiie child died.


    UMBILICAL  HERNIA IN CHILDREN.


  The umbilical  hernia, which is  some-
times formed in the foetus,  from causes
difficult  of explanation,  takes place, in
other   instances, at the moment of de-
livery ; and then, as Sabatier remarks,
should it, by mistake, be tied with the
funis, death would be the consequence.
Most  frequently, however, it is not till
the second, third,  or fourth  month after
birth, that the disease occurs;  and the
numerous cases  collected  by Desault,
prove that, of ten infants  attacked with
this hernia, nine become  afflicted  at the
periods just mentioned.
  The umbilicus, still open, now begins
to contract, so  as to close  the cicatrix,
which, as has been already stated, forms,
in the adult state, an  obstacle  soon  capa-
blcof preventing a protrusion of the vis-
cera, when nothing resists  its  formation.
But,  the  repeated crying  of the child,
propelling  the  viscera outward, pushes
them  through  the opening.  Thus the
cicatrix is forced before them, and they
distend it so powerfully, foifWard, that its
closure is prevented.   Asiheir continued
action gradually dilates it more and more,
the intestines insinuate themselves through
it, increase its natural width, project  be-
yond it, and thus a tumour arises, which,
from being of trivial size at first, becomes
afterwards more considerable; at length,
attains the size of an eeg, or large walnut,
and presents itself with all  the character-
istic marks of a hernia.
  The presence of  a piece  of intestine
and omentum in the  tumour, keeps  the
umbilicus open, and opposes the continual
tendency  which it has to  close.  Such
tendency, however, being sometimes su-
perior to the resistance  of  the protruded
parts, forces them to return back into the
abdomen, obliterates the opening through
which they passed, and thus the sponta-
neous  cure of  the  umbilical  hernia in
children is accomplished.   Two cases il-
lustrative of this fact,  are related  in
(Euvres   Chirurgicales  de  Desault,  par
Bichat, Tom. 2, p. 318.
  Nature, however, does not effect  many
such cures, and when the case Is left to
her alone, she not only fails in bringing
about a radical cure, but gradually ren-
ders it impossible.  In short, the propen-
sity of the opening  to close diminishes,
and is lost, as the subject grows older.
In the adult, it is not the lodgment of the
intestines  in the opening, that prevents
its  obliteration;  it  is its having no
disposition to  undergo this  beneficial
change.
  Hence,  the umbilical hernia of children
seems to be essentially distinguished from
that  of adults, by  the tendency of the
aperture to contract.   Hence the ease of
effecting a radical cure in children,  and
the almost utter impossibility of doing* so
in adults.   In the former, it is enough to
keep the intestines from protruding into
the opening, and it becomes of itself obli-
terated ; in the latter, it always continues,
whether the bowels continue in it or not.
Hence,  the inaccuracy  of  the inferences
deduced by some writers, from the um-
bilical liernia of infants, as  being appli-
cable to that of  adults, and the necessity
of not delaying the assistance of art in the
former cases.
  The means of curing the umbilical her-
nia of children, are of three kinds: exter-
nal applications ;  compression; and tiie
ligature.  The  first  are totally useless;
and, as they occasion  a waste of time, are
improper.  Compression,  and  the  liga-
ture, are the  only rational  plans; and to
these we shall  limit our  observations.
The former is the most modern,  the lat-
ter the most ancient,  as it  was practised
by the Greeks, and then by Celsus.   De-
sault has drawn a most able parallel be-
tween the two modes; he tells us, that
the design both of the ligature  and  com-
nression is the same,  viz. to  prevent the
lodgment  of the protruded viscera in the 
HERNIA
85
opening of the umbilicus, and thus  faci-
litate the approximation of its sides.   To
accomplish this  end, the  ligature  re-
trendies the hernial sac, and skin pushed
before it;  and, by the union of the cut
parts occasions a cicatrix, which hinders
the  protrusion of the viscera.  At  the
same time, the sides ofthe opening, obey-
ing their natural tendency, and affected
by the irritation which they have sustain-
ed, contract, obliterate the opening, and
put the cicatrix in its proper place, though
now it is only  an  accessory means of hin-
dering a protrusion.  "Compression stops
up the aperture by something applied ex-
ternally ; thus, the deficiency, or opening,
in the parietes of the abdomen, hinders
the protrusion of the  bowels, and keep
these parts from resisting the contraction
ofthe sac.  Hence it is clear, that the two
methods are founded on a different basis.
Reason and experience also shew,  that
their results are equally different.
  Though compression occasions no pain,
it causes the child an  irksome inconveni-
ence, during the  great length of time its
employment is necessary.  The ligature
produces momentary  pain;  but there  is
nothing irksome attending its use,  and it
effects in a few days, what  compression,
when successful,  accomplishes in several
months.  In one  plan, continual  atten-
tions are  requisite : should its  employ-
ment be only for a short time neglected,
the previous effect becomes almost de-
stroyed.  The other method always ac-
complishes its  object with certainty, inde-
pendently ofthe crying of the child, and
the care of its attendants.   The first, by
continually compressing the sides  of the
opening, counteracts,  in  this  point  qf
view, its natural  disposition to contract.
The second, by artificially irritating  this
natural  process of the  umbilicus, accele-
rates its contraction.   When compression
is adopted, it is executed either by  means
of a flat compress applied to the opening,
and which  does not enter it, or else by
means of some round or oval body, such
as a ball of wax, a nutmeg,  &c. adapted
to the shape of the aperture, and, as Plat-
ner,  and Richter,  (in his Treatise on Her-
nia) advise, made continually to  enter the
opening.  But, in the  first  case,  if the
bandage be exactly applied,  the skin and
sac,  forming a fold in the aperture  ofthe
navel, will hinder its closure, and operate
in ti»e same manner,  from without, in-
ward,  as the  protruded  intestines  did
from within outward.  In the second case,
the  foreign body, being depressed into
and maintained in the opening, will occa-
sion, notwithstanding what Richter says,
the  same  inconveniences, and, in a more
striking  manner, similar' consequences.
  But, on the contrary, when the ligature
  is employed, tiie sac and skin of the
  tumour are removed, while the opening
  remains free, and nothing prevents  its
  obliteration.  In this method, the omen-
  tum can never protrude  outward; but,
  in the other, if the  compression should
  ever be inexact, the parts slip out again,
  above or below, and tiie disorder prevails
  on one  side  of  the  useless  application.
  Supposing compression successful, both
  plans effect a closure of  the  umbilicus;
  but, while compression only accomplishes
  the latter  object, tlie ligature  has the
  additional advantage of producing an ad-
  hesion ofthe sides of the opening, either
  to each other, or the adjacent parts. This
  adhesive process  arises from  the inflam-
  mation excited, and occasions a degree of
  firmness,  not producible   by any other
  mode of cure.
   To this  parallel, dictated  by reason,
  (continues Desault) let us add that, which
  is the  fruit of experience. On one side,
  we shall  discover,  that  the beneficial
  effects of compression are only reckoned
  in the midst of its want of success, and
  that the children,  on whom it is employ.
  ed, miserably endure for  years its  irk-
  someness and inconveniences.  If we look.
  the other way, we shall  find,  that the
  ligature, which is employed at the Hotel-
  Dieu,  presents an uninterrupted series
  of  well authenticated cures, which,  in
  Desault's practice, amounted to the num-
  ber of fifty.  In the latter years of his
  practice, you might  see  many persons
  bringing to his public consultations their
  cluldren, which were  immediately ope-
  rated on  without any preparation, car-
  ried  home immediately afterwards, and
  brought the next, and every following
  day, to  be dressed,  till  the cure was
 complete.
   To these considerations,  are to be added
 other  motives, which are, perhaps,  not
 immaterial. Tlie children ofthe poor may
  be cured in an hospital, by the ligature,
  in the  space of a  few days.  But, when
 compression is adopted, the parents are
 frequently put to  repeated expence,  as
 tlie bandage wears out; and to additional
 loss' from the time consumed in paying
 the necessary attentions.
   The ancients had different modes of ap-
 plying the ligature ;  but, what they have
  transmitted to us, may be referred to two
 different processes.  One consisted in re-
 ducing the parts, and afterwards tying the
 integuments and sac, without opening the
 latter at all.  In  tlie other,  an  incision
 was made: in the  sac, either before, or
 after tying it, for  the purpose of being
tsure, that no piece of intestine v/as, and
 could  become, strangulated in the liga- 
86
HERNIA.
ture. Celsus adopted the first plan.  Pau-
lus  JEgineta preferred the second, and
was imitated by all the Arabian physicians,
and their successors.  Avicenna, Albu-
casts, and Guy de Chauliac give us proofs
of this in their several works.
  Experience soon decides, which of these
modes of operating ought to be chosen,
One is less painful, and equally safe; for,
we soon become habituated to ascertain-
ing, whether there is still any intestine in
the sac,  by rubbing  the opposite sides of
this bag against each other.  The other,
which is unnecessarily  cruel,  increases
the pain, without  making the method at
all more certainly successful. The latter
has been usually adopted, and Pare, who
has described it, does  not even mention
the former.  Latterly, some variations in
the plan of operating were made.  Some
simply tied  the base  of  the  tumour ;
others passed through it  one,  or two
needles, armed with ligatures for the pur-
pose of fixing such  ligatures in a better
manner,  and even  making, for  this pur-
pose, a circular incision for the lodgment
of them.  It is chiefly'in  the  Arabian
practice,  that we  meet with thi9 cruel
proceeding, which was  also useless, as
the ligature was never known to fadl, when
properly applied.   Par6 also describes  it;
but, Saviard, tlie only modern, who has
practised the ligature,  rejected  it, and
followed the plan long  ago advised  by
Celsus.  Sabatier seems to recommend,
:n his work on the  operations, both plans
indifferently,  with  the exception of the
circular incision. Desault's method, which
much resembles that of Saviard, is simple,
and attended with little  pain : in short, it
is the following:
  The child, on whom the operation is to
be done,  must be placed on its back, with
its thighs a Utile  bent, and its head in-
clined  towards  the chest.  The surgeon
is to reduce tlie protruded parts, forming
the tumour, and to hold them so with his
finger, at the same, time, that  he raises
the hernial sac, and rubs its sides between
his fingers, so as to be sure, that there is
nothing  contained  in it.  Being certain,
that the  parts, which he lifts up, are only
the skin and sac, he  is to direct an assist-
ant to  surround their base several times
with a waxed ligature, of middling size,
each turn being tied with a double knot,
in such a manner as only to occasion little
pain.   The tumour,  thus tied,  is to  be
covered with lint, which is to be support-
ed with  one  or two compresses, and a
circular bandage, secured with a scapu-
lary.  A  slight swelling commonly takes
place in the constricted parts, by the fol-
   No pain accompanies this tumefaction,
which is itself often scarcely perceptible,
as may be seen by referring to the first
case of this operation related in the Pari-
sian Journal.   On  the  second, or third
day, tlie parts shrink, and then tlie liga-
ture becomes loose,  so that a fresh one
must now be applied in the same manner
as the first, taking care to draw it a little
more tightly.  The sensibility of the parts,
increased by the inflammation, which the
constriction of the  ligature has already
produced, usually renders this second h-
gature more painful.  After the operation,
the same dressings, as before,  are  to  be
applied.  The tumour soon becomes dis-
coloured, livid,  and smaller   A third
ligature, put  on in the same way as the
preceding ones, entirely obstructs the cir-
culation in it.  The  part turns  black and
flaccid,  and commonly falls off on the
eighth or tenth day.  A small ulcer is left,
which, being  properly dressed very soon
heals, and  leaves  a cicatrix sufficiently
strong to resist the impulse occasioned  by
coughing, or other efforts of the abdomi-
nal muscles.   For two, or three months,
however, after the operation,  the child
should wear a circular bandage, in order
to prevent, with still more certainty, the
viscera from being  propelled against the
cicatrix,  so as to interrupt the process  of
nature, which  is now producing a gradual
closure of the  umbilical opening.  Nume-
rous cases might  here be  adduced,   in
confirmation of the above practice; but,
several (nine) are already published  in
the Parisian Chirurgical Journal. The re-
lation of others here would only prolong
our observations in  a fruitless manner.
Suffice it to remark, that since those al-
luded to  were published,  Desault has
practised an infinite number of operations
of tins  sort with  equal  success;  that,
every week, many children were brought
by their mothers into the amphitheatre,
where he publicly delivered  his lectures;
that  here  the  ligature was applied in the
presence of all his pupils; and that chil-
dren, thus  operated upon, were carried
home, and  brought back  every day to be
dressed, till the cure was completed.
  But, one  may doubt,  (says  Sabatier)
quoting the article in the journal, where
Desault treats of  the  present disease,
whether the infants got rid of the hernia,
as it might have returned some time after-
wards. Numerous facts remove this dinibt;
for, several of the  subjects were brought
to Desault's public consultation, for their
diseases, a long while after they had been
operated upon, and the great number  of
students, who examined them, all acknow-
lowing day, just as a polypus swells, afterlTledged, that the ring was completely obU-
its base has been tied.                    terated, and there was no impulse of the 
HERNIA.
87
viscera in coughing, sneezing, &c.  Other
children, in the knowledge of the sur-
geons of the Hotel-Dieu, have remained
perfectly cured of their umbilical herniae,
by the operation,  which Desault has  re-
vived.  Bichat  is  acquainted with two
young subjects,  who were operated  on
four years ago,  and have  since had  no
relapse.
  The operation is almost  certainly suc-
cessful in young infants ; but, it becomes
less so,   in proportion as  their age  in-
creases.  Bichat relates three cases, which
tend  to  show,  that success may be com-
pletely obtained at the age  of a year and
a half; that the cure  is difficult, when
the child is four years old; and impossi-
ble, when it" is nine.   Several other ope-
rations,  done   too late, have had   the
same result.  (See QZuvres  Chirurgicales
ik  Desault, par Bichat, Tom. 2, p. 315,
&c.)
  Mr. Pott  notices the plan of curing  the
exomphalos  widi the  ligature,  and  ex-
presses himself strongly against the prac-
tice in general.  To adults* the plan is
 not applicable,  particularly,  when   the
 tumour  is large.  Mr.  Pott was  decid-
 edly  in  favour of compression, and he
 observes, that, in young  subjects,  and
 small hernix, a bandage, worn a proper
 time, generally proves a  perfect  cure,
 {Vol 2.)               '
   Anxious  that  this  work should  be
 strictly impartial, I next proceed to relate
 what has been  recently* urged against  tiie
 employment of tlie ligature for the cure
 of the  umbilical hernia in children,  and
 to  notice the   observations,  which have
 been adduced in favour of the treatment
 by compression.
   The incessant care that a bandage re-
 quires,  either  to keep it clean, or make  it
 always keep up the proper degree of pres-
 sure, renders its employment difficult in
 the children of the poorer  classes.  Scar-
 pa expresses his opinion, that " this  was
 what induced Desault to revive the opera-
 tion for the umbilical hernia by the liga-
 ture, nearly such as  is described  by Cel-
 sus,  an operation  (continues  Scarpa),
 which,  a long while since, and  for good
 reasons, was altogether abandoned.  Cel-
 sus has  sufficiently described the particu-
 lars  of it: (Lib  7,  Cap.  14.)  he  states,
 that the tumour is sometimes to  be sim-
 ply tied, and that, in other instances, its
 base is  to  have a needle and double liga-
 ture introduced through it, in order  that
 it  may  be  embraced almost in  the same
 way as a staphyloma is tied. But, amongst
 the  causes,  which  contra-indicate  this
 operation,  he  mentions so many circum-
 stances, in  relation  to age, constitution,
diseases of the skin, &c. that he seems to
consider the  cases, in which  it may be
practised with success, as very few.  The
same reflections have been made  by seve-
ral other ancient surgical writers, espe-
cially,  by  Fabricius  ab  Aquapendente.
Desault himself has put some restrictions
to the  employment of the ligature, since
he observes, with his usual candour, that
this method does not radically cure the
umbilical hernia of children,  arrived at
the  age of four years; that  it is indis-
pensable, as Celsus inculcates, to employ
a needle and  double  ligature, when the
base of the tumour is very large; and,
lastly, that, even in the youngest children,
a radical cure  cannot be effected  by the
ligature, unless a methodical compression
of the  navel,  by means of a bandage,  be
kept up immediately after the operation,
and for two or  three months. It is per-
haps to the omission  of this last  means,
that a relapse isvto be  ascribed in  several
of the children operated upon by Desault.
" Desault avoit remis en vigueur la ligature
tombee en desuetude.  II s'abusoit sur sa va-
leur,- et il n'est pas difficile (Fen connoitre la
 muse.  Tous les enfans qu'il operoit d I'Ho-
 tel-Dieu sortoient gueris et n'y revenoient
plus: on regardoit alors comme radicale une
guerison momentanee."  (Nosographie Chi-
rurgicale, Tom. 2, p. 453, par Richerand)
I have carefully watched  (says Scarpa)
 the immediate effects, and the more or
 less remote consequences of tying the um-
 bilical hernia,  either simply, or by means
 of a needle and double ligature; and, after
 a considerable number of such cases, I be-
 lieve I can assert, that tins operation, how-
 soever performed, is not always exempt from
grave  and sometimes dangerous accidents.
 I can also add, that it never procures a truly
 radical cure, unless the cicatrix, occasioned
 by it in the umbilical region, be submitted for
 some months to  a methodical and uninterrupt-
 ed compression.  It is  not so uncommon, as
 some surgeons pretend, to see arise after the
 application oftlu; ligature,  a fever attended
 with symptoms  of most violent irritation, and
 acute sufferings,  w/uch cause incessant cry-
 ing, and sometimes convulsions.   The ulcer,
 which is produced by the detachment of the
 swelling, is always very large and difficult to
 heal.   Every now and then it becomes pain-
ful, and emits fungous granulations, even
 though dressed with dry applications.
   " Latterly,  it has been explained by a
 celebrated surgeon, (Paletta Memor. delV
 Instituto, Tom. 2, Part 1.)  that the umbi-
 lical vein and the suspensory  ligament of
 the liver,  being included in the  ligature
 ofthe  umbilical hernia, the inflammation,
 which originates in these parts may, per-
Vhaps, in certain cases, be communicated 
88                                 HERNIA.
  to the liver, so as to put  the  child's life
  in great danger.  When,  in consequence
  of the ligature, symptoms of violent irri-
  tation come on, they are ordinarily attri-
  buted to certain individual circumstances,
  such as extreme sensibility, or a particu-
  lar disposition to spasm.   Hence,  it is
  believed, that they should be  considered
  as exceptions, which do not exclude the
  general  rule, and prove nothing  against
  the utility  of the operation.  But,  how
  (says Scarpa)  can the  surgeon ascertain
  the existence, or non-existence of these
  individual dispositions,  in  the children,
  upon which he is to operate ?   Assuredly,
  those subjects, in which I have had occa-
  sion to  notice the above accidents,   en-
  joyed, before the operation, perfect health
  in every respect.
    u,Whatever  process  be  adopted   for
  tyi^Sig  the umbilical hernia, it is evident,
  that the tumour can only be constricted
  as  far as a little way on this side of the
  aponeurotic ring ofthe umbilicus, whence,
  it follows, that the integuments must al-
  ways remain prominent  and relaxed for a
  certain extent, at the front and circum-
  ference of this opening. Also, after  the
 separation of the strangulated portion,
 there necessarily remains, under the cica-
 trix, a portion of the hernial sac,  and of
 the loose  integuments, which covered it;
 and as the cicatrix itself never acquires
 sufficient firmness to resist the impulse of
 the viscera, which tend to insinuate them-
 selves into the remains of the hernial sac,
 the hernia sooner or later reappears, i-.nd,
 in  a short time, becomes larger, than it
 was before .the operation. If the subject
 is a little girl, it may  be  apprehended,
 that the first pregnancy will cause  a  re-
 currence  of  the heniia;  for,  it  is known,
 that, during gestation, the external cica-
 trix of  the umbilicus, is  considerably dis-
 tended, and much disposed to give way."
   Pott  has seen terrible  accidents caused
 by the rupture of the cicatrix at the na-
 vel, during pregnancy.  (Chirurg. Works,
 Vol. 2, p. 169.)  It is true,  that accord-
 ing  to this writer, tliis  cicatrix was not
 the consequence of a hernia, but rather
 of an abscess  in  the  umbilical region,
 which abscess had formerly been opened
 with  a  bistoury;  yet, observes Scarpa,
 it would not be impossible to raise doubts
 upon this  conjecture.  Lastly,  after the
 separation of the tumour, there always
 remains, between the aponeurotic ring  of
 the navel,  and  the integuments, a  small
 cavity, formed by the neck of the hernial
 sac ; a cavity, into which the viscera be-
gin to insinuate themselves after  the ope-
ration, so as to hinder the complete  con-
traction of the umbdical ring.   The de-
monstration of what 1 have  advanced  is,
   in some measure  to be found, in the old
   method of operating for the inguinal her-
   nia,  not in a strangulated state,  by the
   ligature of the hernial sac and spermatic
  * cord.  It-is well known, that most of the
   hernis, operated upon  by this barbarous
   process, were subject to relapses, because,
   in all probability, the  cicatrix was not
   sufficiently firm to resist the impulse of
   the viscera, which entered the remains of
   the hernial sac.   In  the same manner,
   after the common operation for the stran-r
   gulated inguinal hernia, although the ci-
   catrix is formed very near the ring, there
   is no prudent surgeon,  who does not ad-
   vise the  patient to wear a  bandage the
   rest of his life,  observation having prov-
  ed that the hernia is still liable to recur.
     " An experience of several ages  (ob-
  serves Professor Scarpa) has put  out of
  all doubt,  that  compression  alone is an
  extremely efficacious method of radically
  curing the umbilical hernia of young sub-
  jects.  It is attended  with no risk, and,
  provided  it be executed with the  requi-
  site caution, it is hardly ever necessary
  to continue it longer, than two, or three
  months,  for the purpose of  obtaining a
  complete  cure.  On the  other side, if it
  be clearly proved, by all that I have been
  observing,  that the ligature never accom-
  plishes a  perfect cure without compres-
  sion, it  is manifest, that it cannot  be at
  all advantageous  for the children of the
  poor, since a bandage cannot be dispensed
  with.  It  may hi  said, that,  in  general,
  it  does  not shorten the treatment;  for,
  in  the most successful cases, the ulcer,
  caused by it, is not healed in less than a
  month, and, in order to make the cure
  certain, an exact compression must  after-
  wards be kept up, by means of a bandage,
  two months longer.  It has already been
  stated, that  three months are ordinarily
  sufficient for obtaining  a  radical cure by
  the  mere  employment  of a compressive
  bandage."  (Scarpa, Traite des Hernies, p.
  344—349.)                           r
   It appears from a note,  which M. Cayol
  has inserted  in the French translation of
  Scarpa's  work  on liernia, that M. Girard
  has published in the Journal General  de
  Medecine,  Tom. 41, Cahier  de  Juillet,
  1811, a memoir on  the umbilical hernia
  of children, which was read to the Medi-
 cal  Society of Lyons in May,  1811, and
 the object of which was to recommend
 compression as an effectual means of cure.
 The arguments used were very similar to
 those adduced by Scarpa.  In the course
 of the  discussion,  M.  Cartier  affirmed,
 that he had seen many children operated
 Jipon by Desault,  who were not cured of
Hbeir hernia.
   The  subject  was afterwards taken vf 
HERNIA.                                89
by tttc Medical Society of Paris, and the
result of the debate was, that the employ-
ment of the ligature ought to be rejected.
1. Because the  cure  of umbilical herniae
is very often accomplished by the power
of nature alone.  2. Because compression,
either alone, or aided by tonic  remedies,
always  succeeds.  3. Because the opera.
tion bf the ligature deserves the triple re-
proach of being painful, and not free from
danger, if unfortunately a piece of intes-
tine should chance to be  included in the
ligature;  of not  succeeding  in general,
unlesslwith the assistance of compression;
and of being  sometimes uselessly prac-
tised,  as Desault himself gives  us  in-
stances of.
  It is  farther stated by M. Cayol, that
the majority of judicious surgeons have
long since acknowledged the insufficiency
of the ligature for the radical cure of the
umbilical hernia; Sabatier, Lassus,  Ri-
cherand. &c.

  UMBILICAL HERNIA  IN ADULT SUBJECTS.

  This case is to be treated on the prin-
ciples common to all ruptures.  When
reducible, the  parts  should be kept up
with  a bandage,  or truss; which plan,
however, at this period of iife, affords no
hope  of a radical cure.  Mr.  Hey has
described one of the best trusses for  the
exomphalos, which  is applicable to chil-
dren, when compression is preferred, as
well as to adult subjects.  It was invented
by Mr. Marrison, an ingenious mechanic
at Leeds.
   " It consists of two pieces of thin elas-
tic steel, which surround the sides of the
abdomen, and  nearly meet behind.  At
their anterior  extremity they form con-
jointly  an oval ring,  to one side of which
is fastened a spring of  steel of the form
 represented.  At  the end of  this spring
 is placed the pad or bolster that presses
 upon the hernir..  By  the elasticity of
 this  spring the  hernia  is repressed  in
 every position ofthe body, and is thereby
 retained continually  within the abdomen.
 A piece of calico or jean is fastened to
 each  side of the oval ring,  having a con-
 tinued loop at its edge,  through which a
 piece of tape is put, that may be tied be-
 hind  the body.  This contrivance helps
 to preserve the  instrument steady in  its
 proper situation," (Practical Obs. in Sur-
gery, p. 231.)
   When the  exomphalos  is  irreducible,
 and large, the tumour must be supported
 with bandages.
   It  is observed by Professor. Scarpa,
 that  the umbilical  hernia, and those of
 the linea alba, are less subject to be stran-
 gulated, than the inguinal and  femoral
      Vol  11
hernia:; but that,  when they are unfortu-
nately affected  with strangulation, tiie
symptoms are more intense, and gangren«
comes on  more  rapidly, than in  every
other species of rupture.  If the opera-
tion be performed, the event is frequently
unfavourable, because it is generally done
too late.  This  practical fact is  proved
by tlie experience of the most celebrated
surgeons of every age.   " II est certain
(says Dionis) que de cette operation il en
perit plus qu'il n'en rechappe."   (Court
d'Operation,p.98, Edii.1777, aveclesnotes
de La Faye.)  He also adds, that they,
who have the misfortune to be afflicted
with an exomphalos, should rather dis-
pense  with their shirt, than  a bandage.
Heister says nearly the same thing.  (In-
stit. Chirurg. Tom. 2, Cap. 94.)
   It is further remarked by Scarpa, that
when the omentum alone is strangulated
in the exomphalos, or herniae of the linea
alba, observation proves, that the  symp-
toms are not less intense, than when the
intestine is  also  incarcerated. There is
this difference, however, that when  the
omentum alone is  strangulated, only nau-
sea occurs, and, if vomiting should like-
wise take place,  it is less frequent and
violent than when the bowel itself is stran-
gulated.  In the first case, the stools are
hardly ever entirely  suppressed.   The
proximity of the  stomach  is, no doubt,
the reason, why the strangulation of the
omentum, in the  umbilical hernia, occa-
sions far more  intense symptoms of sym-
pathetic  irritation,  than the  strangula-
tion ofthe same viscus in the inguinal, or
criual hernia.
   Here, says Scarpa, the operation is not
only always necessary, but urgently  re-
quired.   It is  not materially different
from  that, which is  practised  for  the
strangulated inguinal and crural herniae ;
but, in general, it demands  greater cir-
 cumspection, on account ofthe connexion,
 or intimate adhesions,  which  frequently
 exist, between the  integuments  and her-
 nial sac, and also the  adhesions,  which
 often prevail between the latter part and
 the omentum which it contains.  The si-
 tuation  of the intestine, which  is  fre-
 quently covered by, and enveloped in the
 omentum,  is another  circumstance de-
 serving earnest attention. (Scarpa, Traite
 des I ferries, p. 361, 36'2.)
   Mr. Pott is not such an advocate as
 Scarpa, for  the early performance of the
 operation  in  cases"  of exomphalos: —
 " The umbilical, like the inguinal  her-
 nia, becomes the subject of chirurgie ope-
 ration, when the parts  are  irreducible by
 the hand only) and are so bound as to
 Ereduce bad  symptoms.   But though I
   ave  in thje inguinal and  scrotal hernia
     M 
90                                HERNIA
 advised the early use of the  knife, I can-
 not press it so much in this :. the success
 of it  is very rare, and I should  make
 it  the last  remedy.  Indeed I  am much
 inclined to believe, that the bad symptoms
 which attend these cases are most  fre-
 quently owing to  disorders in  the intes-
 tinal canal, and not so often to  a stricture
 made on it at the navel, as  is supposed.
 I do not say that the latter does not some-
 times happen, it certainly does; but it is
 often  believed to be the case  when it is
 not.
   [On this opinion of  Mr. Pott's I take
 the liberty to remark, that no  surgeon
 ought to undertake an operation for tiie
 cure  of hernia, unless certain that  the
 hernia exists   If an umbilical hernia  be
 strangulated, it calls as loudly for  the
 operation as  any other, and  I see no rea-
 son why it should be longer delayed.]
   " When the operation becomes  neces-
 sary,  it consists in dividing the skin and
 hernial sac,  in such manner as shall set
 the intestine free from  stricture,  and en-
 able the surgeon to return it into the ab-
 domen."  (Pott on Ruptures.)
   The rest of the  conduct of the surgeon
 is to be regulated by the usual  principles.
   The division of the stricture is proper-
 ly recommended to be made directly up-
 ward, in the course of the linea alba.
   In eonsequence  of the great fatality of
 the usual operation for the exomphalos, I
 think  the plan suggested, and successfully
 practised by  Mr. A. Cooper in  two in-
 stances, should always be adopted, when-
 ever the tumour is at all large, and free
 from gangrene;  a plan, that has also re-
 ceived the high sanction of that distin-
 guished anatomist and surgeon. Professor
 Scarpa. (Traite des Hernies, p. 362.)   I
 might, perhaps,  safely add, that when the
 parts admit of being reduced, without lay-
 ing open the sac, this  method should al-
 ways  be preferred.  It consists in only
 making an incision sufficient to  divide the
 stricture, without opening the  sac at all,
 or, at  all events no more of it,  than is in-
 evitable.
   In umbilical hernia:, of not a large size,
 Mr. C. recommends the following plan of
 operating: " As the opening into the ab-
 domen is placed towards the upper part
 of the tumour, 1 began the incision a lit-
 tle below it, that is, at the middle ofthe
 swelling, and  extended  it to its  lowest
 part.  I then  made a  second incision at
 the upper part of the first, and at right
 angles with it, so that the double incision
 was  in the form of the letter T,  the top of
 which crossed the middle of the tumour.
 The integuments being thus divided, the
angles  of the  incision were turned down,
which  exposed a considerable portion of
 the hernial sac.  This  being then  care.
 fully opened, tiie finger was p.issed liclow
 the intestines  to  the orifice of the sac at
 the umbilicus, and the probe-pointed bis
 toury being introduced upon it, I directed
 it into the  opening at the navel,  and di-
 vided the  iine» alba downwards, to the
 requisite degree, instead of upwards,  as
 in the former operation.  When the omen-
 tum  and intestine arc returned,  the por-
 tion  of integument and sac, which is left,
 falls  over the opening  at  the  umbilicus,
 covers it, and unites to its edge, and thus
 lessens the risk of peritoneal inflamma-
 tion, by more readily closing the  wound."
 (On  Crural and Umbilical Ifcrtua.)
   [Mr.  Lawrence  remarks  that in old
 umbilical herniae there is generally found
 a considerable portion of omentum ad-
 hering to the sac.  About two years ago
 I operated on a case of umbilical hernia,
 in which the sac differed from any 1 have
 seen  described.   Upon cutting  into  it
 I found a portion  of  ilium,  ten inches  in
 length, strangulated in several places, by
 bands passing in all  directions from the
 sac to  the omentum,  forming a cavity
 much resembling  the  ventricles of the
 heart.  The omentum,  and the  sac  had
 been  blended together  in this way proba-
 bly for  years.  The intestine was net a
 part of the usual contents of the  sac, but
 had been forced into this singular cavity
 and  become strictored  in four  distinct
 places by these productions.  It was ne-
 cessary by  very careful  dissection to di-
 vide, these  bands and liberate the struc-
 tured intestine, which was accomplished,
 and the intestine evidently not being gan-
 grenous was returned into the abdomen.]

    LKSS FUEO.UENT KINDS OF HERNIA.

  The ventral hernia, described by Celsus,
 is not common ; it may appear  at almost
 any point of the anterior part ofthe belly,
 but, is most frequently found between the
 recti  muscles.  The portion  of intestine,
 &c. is always contained in a sac,  made by
 the protrusion of the peritonaeum.  Mr. A
 Cooper  imputes its causes to the dilata-
 tion ofthe natural foramina for the trans-
 mission of  vessels, to congenital deficien-
 cies,  lacerations,  and wounds, of the ab-
 dominal  muscles, or their tendons.  In
 small ventral herniae, a second  fascia  is
 found beneath the superficial one; but, in
 large  ones, the latter is the only one cov-
ering the sac.
  Herniae in the course of  the linea alba
sometimes  occur  so  near the umbilicus,
that  they  are liable to  be mistaken for
true umbilical ruptures.  They may take
place  either above, or below the navel.
TLe first case, however, is more fre:ju.-u^ 
HERNIA.
91
than the  second, and thp following is the
reason of this  circumstance according to
the opinion of Scarpa.   " l he upper half
of the linea aiba, that which extends from
the ensiform cartilage to the umbilicus, is
naturally broader and  weaker, than the
lower halt', the recti muscles becoming
nearei*»and nearer together, as they des-
cend from the navel to the pubes." (Scar-
pa, Traite des Hernies,  p. 333)
   The hernial sac of ruptures at the up-
per part of the linea alba  may contain a
noose of intestine,  and  a piece of the
omentum, though,  in most cases, a por-
tion of the latter membrane alone forms
the contents.  In some subjects, the linea
alba is so disposed to give way, that seve-
ral herniae are observed to be formed suc-
cessively  in the interspace between the
ensiform cartilage and the umbilicus.
   " With respect to the small hernia (says
Scarpa) which is considered as formed  by
the stomach, and concerning which Hoin
and  Garengeot have  written  so much
(without either of  them havmg related,
at least to my knowledge,  a single exam-
ple proved by dissection), it  is at least
unproved, that it was exclusively formed
 by this  viscus.  I  do not  see, why the
 other viscera, particularly the omentum
 and transverse colon, might not also con-
 tribute to it.   In my  judgment, it only
 differs  from  other herniae of  the linea
 alba, in being situated on the left  side of
 the ensiform  cartilage, a  situation, that
 must materially influence  the  symptoms
 of the case.  In fact, whatever may  be
 the viscera, which  form it,  a sympathetic
 irritation of the stomach is  occasioned,
 that is much more intense, than that which
 ordinarily accompanies umbilical herniae,
 those of the lower  part of the linea alba,
 or, in short,  all other herniae, which  are
 more remote from the  stomach."  (Op.
 cit. p. 334.)
   The following are said to  be the cir-
 cumstances, by  which the umbilical her-
 nia,  and that which occurs in  the linea
 alba near the navel, may be discriminated.
   The first, whether in the infant, ofthe
 adult, has a roundish neck, or pedicle, at
 the  circumference of which the aponeu-
 rotic edge of the  umbilical ring can  be
 felt.   Whatever may be its size, its body
 always retains nearly  a spherical s.hape.
  Neither at its apex, or its sides, is  any
 wrinkling of the skin, or any  thing  like
 the cicatrix of the navel,  distinguishable.
 In some points of the surface of the tu-
 mour, the skin is  merely somewhat paler
 and  thinner,  than  elsewhere.
    On the contrary, the hernia ofthe linea
 alba has a  neck,  or pedicle of an oval
 form, like the fissure, through which it
  is protruded.  The body of the tumour
is also constantly oval.  If the finger be
pressed deeply round it s neck, the edges
ofthe ope.iing in  the  tinea alba can be
felt;  and, if  the hernia be situated very
near  the  umbilical ring, the cicatrix of
the navel may be observed upon one  side
of it,  which cicatrix retains its  rugosity
and all  its natural appearance; a certain
indication, that  the viscera are not  pro-
truded through the umbilical ring.  (Scar-
pa,  Traite des Hernies, p. 336.)
  The distinction,  which Scarpa has es-
tablished between  the  umbilical hernia,
properly so called,  and those ofthe linea
alba,  is not useless in regard to practice.
Indeed, when the latter are left to them-
selves,  they make much  slower progress
than tlie former.  On account of their small-
ness, they frequently escape notice, parti-
cularly  in fat persons, and, when situated
at the  side  of the eiisiform  cartilage.
They occasion, however, complaints ofthe
stomach, habitual Colics, especially  after
meals;  and, unfortunately for the patient,
he may be tormented a very long time by
these indispositions, before the true cause
of them is discovered.
  The  umbilical hernia may be known,
from tlie earliest period of its  formation,
by the alteration which it produces in the
cicatrix of the navel, and the rapidity of
its increase.
   In other respects, these two kinds of
 herniae demand  the same means of cure ;
 but,  those of the linea alba,  cxteris pari-
 bus,  are more difficult to cure, than rup-
 tures at the  umbilicus.  This is probably
 owing to the natural tendency, which the
 umbilical ring has to close, when the her-
 nia  is kept well  reduced, whilst acciden-
 tal  openings in the linea  alba, have not
 the same advantage. (Scarpa, p. 340.)
   When a common ventral hernia  is re-
 duced,  it should be kept in its  place by
 means  of a bandage or truss. When stran-
 gulated, it admits, more frequently than
 most other cases, of being  relieved by
  medical treatment. If attended with stric-
  ture, which  cannot otherwise be relieved,
  that stricture must be carefully divided.
  Mr. A. Cooper recommends the valvular
  incision,  and the dilatation  to  be made,
  either upward,  or  downward,  according
  to the relative situation of the tumour and
  epigastric artery, which crosses tlie  lower
  part ofthe linea semilunaris.
    Pudendal  Hernia.— This is the  name
  assigned by Mr. A. Cooper, to that which
  descends between the vagina and ramus
  iscliii,  and  forms an oblong tumour  in
  the labium, traceable  within the pelvis,
  as far as the os uteri,  Mr. C. thinks this
  case has sometimes been mistaken for a
  hernia of the foramen ovale.  When redu-
  cible, a common female bandage,  or the 
92
HERNIA.
truss used for a prolapsus ani, should be
worn  A pessary, unless very large, could
not very well keep the parts from descend-
ing, as the protrusion happens so far f om
the  vagina.  Mr. C  is of opinion,  that,
when strangulated,  this hernia, in conse-
quence of the yielding nature of the parts,
may generally be reduced, by pressing
them with gentle and regular force, against
the inner side ofthe branch ofthe ischium.
If not,  the warm bath,  bleeding, and to-
bacco glysters, are advised. Were an ope-
ration indispunsable, the incjsion should
be made in the labium, the lower part of
the sac carefully opened, and, with a con-
cealed  bistoury, directed by the finger, in
the  vagina, the stricture should  be  cut
directly inward, towards the vagina. The
bladder should be emptied, both before
the  manual  attempts  at reduction,  and
the operation.  (On Crural Hernia,  &c.
p. 64.)
  Vaginal Hernia —A tumour occurs with-
in the os externum.  It is elastic, but not
painful  When compressed,  it readily re-
cedes,  but, is reproduced by  coughing, or
even without this when  the pressure is
removed.   The inconveniences produced
are an inability to undergo much exercise,
or exertion; for, every effort of this sort
brings  on a sense of  bearing down.  The
vaginal hernia protrudes in the space, left
between the uterus and rectum. This
space is bounded below by the peritonaeum,
which  membrane is forced downwards to-
wards  the perinacum ; but, being unable
to protrude further  in that  direction, is
pushed towards the back part of the va-
gina.  Mr. C. advised the use of a pessary
in one case; the plan, however, was neg-
lected.  These cases, probahly, are always
intestinal.
  Some herniae protrude at  the  anterior
part of the vagina. (See Mr  . 1. Cooper on
Crural Hernia, &c. p. 65,' 66.)
  Perineal Hernia.—In men, the parts pro-
trude between  the bladder and rectum ;
in women, between  the  rectum and va-
gina.  The hernia does not project, so as
to form an external tumour, and, in men,
its existence can only be distinguished by
examining in the rectum.  In  women, it
may be detected both from this part,  and
the vagina.
   In case  of strangulation, the hernia
might,  perhaps, be reduced by pressure
from within the rectum.   An interesting
case of jierineal hernia, which took place
from the peritonaeum being wounded with
the gorget in lithotomy is related by Mr.
Bromfield;  Chirurgical Observation,*, f>.
264.                                ^
  The  reducible perineal hernia in women
may be kept from descending, by using a
large pessary.  Both this kind of rupture
 and the vaginal may prove very dangermii
 in cases of pregnancy.  See Smellie's Mid-
 wifern,  Case, 5.
   Tlnjroideal Hernia, or Hernia Foramhiin
 Oralis.  In the  anterior and upper part
 of  the  obturator  ligament,  there  is an
 opening, through which the obturator ar-
 tery, vein, and nerve proceed, and t.^oiv^h
 which, occasionally, a piece of omentum,
 or intestine is  protruded, covered  with a
 part of the peritonaeum, which constitutes
 the hernial sac.
  In the Case, which Mr. A.  Cooper met
 with, the hernia descended above the ob-
 turatoies muscles.  The os pubis w.ts be-
 fore the neck of the sac: three-fourths of*
 it were surrounded by  the obturator liga-
 ment ; anil the fundus of the sac lay be-
 neath  the pectineus and adductor hrevis
 muscles.  The obturator nerve and artery
 were situated behind the neck of the sac,
 a little towards its inner side.  This spe-
 cies of hernia Can  only form an  outward-
 tumour,  when very large.   Garengeot,
 however, met with an  instance,  in which
 there was  not only a  swelling,  but, one
 attended with  symptoms of strangulation;
 he  reduced the hernia, which  went up
 with a guggling  noise;  the symptoms
 were stopped, and stools soon followed.
  The hernia of the foramen  ovale,  when
 reducible,  must be kept up With a suita-
 ble truss; and when strangulated, and not
 capable of reHef from the usual means, an
 operation would be requisite, though at-
 tended with difficulties.  The division of
 the obturator ligament and month ofthe
 sac should be made inwards,  to avoid the
 obturator artery.  This vessel,  however,
 would  even be exposed to  injury by fol-
 lowing this plan, if it should arise in com-
 mon with the  epig-istric artery.  (See a
paper by  Garengeot in  Mem.defAcud.de
 Chir. torn. 1; and A. Cooper on Crural Her-
 nia, &c. p. 70.)
  Cystocefe—As Mr. Pott observes,  "The
 urinary bladder is also liable to be thrust
 forth  from  its proper situation,  either
 through the opening in the oblique mus-
 cle, like the  inguinal hernia, or  under
 Poupart's ligament, in the same manner
 as the femoral.
  " This is not a very frequent species of
 hernia,  but does happen, and has as plain
 and determined a character as any other.
  " It h:..s been  mentioned by Bartholin,
 T. Dom. Sala,  Platerus, Bonetus, Ruysch,
 Petit, Mery, Yerd.cr, &c.  In one  of the
 histories given by the latter, the urachus,
 and impervious  umbilical  artery on  tl: .■
 left side, were drawn through the tei-d'.:i
 into the scrotum,  with the  bladder; in
 another he found four calculi.
  " Ruysch gives an account  of one com-
 plicated  with  a  ir-crt'l!'-.!.  1'".:;-"!'<.tj? 
HERNIA.
23
Mr. Petit says iie feit several calculi in
one>  which were afterwards discharged
through the urethra.
  " Bartholin speaks of T. Dom. Sala as
the first  discoverer of the  disease, and
quotes a case from him,  in which the pa-
tient had all the symptoms  of a stone in
his bladder; the stone could never lie felt
by the sound, but was found in the bladder
(which iiad passed into  the  groin)  after
death.
  " As tlie bladder is only covered in part
by the peritoneum, and must insinuate
itself between  that membrane  and the
oblique muscle, in order to pass the open-
ing in the tendon, it is plain  that the her-
nia cystica can  have no sac, and  that,
when complicated with a bubonocele, that
portion  of the bladder  which forms the
cystic hernia must lie between tjie intes-
tinal hernia and the  spermatic chord, that
is, the intestinal hernia  must be anterior
to the cystic.
  " A cystic hernia may indeed be the
cause of  an intestinal one;  for when so
much of  the bladder has passed the ring,
as to drag  in the upper and hinder part
of it, the peritoneum which covers that
part must  follow, and by that  means a
sac be formed for the reception of a por-
tion of gut or caul.   Hence  the  different
situation of the  two hernix  in the same
subject.
   " While recent* this  kind of hernia is
easily reducible,  and may, like the others,
be kept within by a proper bandage; but
when it is of any date, or has arrived to
any considerable size, the urine cannot be
discharged, without lifting up, and com-
pressing  tlie scrotum ; the outer surface
ofthe bl.idder is now become adherent to
:ne cellular membrane, and the patient
must be contented with a suspensory bag.
   " In case of complication  with a bubo-
nocele, it the  operation becomes neces-
sary, great care must be taken not to open
the bladder instead of the sac, to which
it will always  be found to  be posterior.
And it may also sometimes by  the inat-
tentive be mistaken for a hydrocele, and
by being treated as such, may be the oc-
casion of great  or  even  fatal  mischief."
(Vol 2.)
  The cystocele  is always  easily distin-
guishable by  tlie regular diminutien  of
the swelling, whenever the patient makes
water.
   Verdier  and Sharp have accurately de-
scribed the cystocele.   Pott has offered
two  cases, which fell under his observa-
tion;  Vnl.  3. Pipelet le Jeune mentions
a cystic  hernia  in  perinaeo, and several
crises of  its occurrence in the female;
. lead, de Chir. torn 4.  Pott cut into one
;;;,•».♦.>cHe,  by mistake.  Mention is made
(Edinb. Surg. Jourtt.  vol.  4. p. 512.)  of a
cystic  hernia, which  protruded between
the origins of the levator ani, and obtura-
tor internus muscles: the tumour made
its appearance in the pudendum of an old
woman.  Gunz and Hoin have also treat-
ed of the cystocele.
  Ischiatic Hernia.—The case is probably
very rare.  A case, however, which was
strangulated, and undiscovered till after
death, is related in  Mr. A. Cooper's  se-
cond  part of his  work  on hernia.  It is
communicated by Dr. Jones,  already cele-
brated for his book on hemorrhage.  The
disease happened in  a young man, aged
27.  On opening the abdomen,  the ilium
was found to h:tve descended  on the right
side of the rectum into the  pelvis, and a
fold of it was protruded into a small sac,
which passed out  of the pelvis at  tlie
ischiatic notch.  The intestine was adhe-
rent to the sac at two points: the stran-
gulated part, and about three inches on
each  side, were very black.  The intes-
tines towards the stomach were very much
distended with air, and, here and there,
had a livid spot on them.  A dark spot
was even found on  the stomach  itself just
above  the pylorus.  The  colon was ex-
ceedingly contracted,  as  far as its  sig-
moid flexure.  A small orifice was found
in the side of the pelvis, in front of, but a
little  above, the sciatic nerve, and on the
forepart of the pyriformis muscle.  The
sac lay under the glutaeus maximus mus-
cle, and its orifice was before the internal
iliac artery,  below the  obturator artery,
but above the vein.  Mr. A. Cooper re-
marks, that a reducible case might be kept
up with a spring truss, and, that if an
operation were requisite, tiie orifice of tiie
sac should be dilated directly forwards
(On Crural liernia, Hie.p. 73.)
   Phrenic Hernia. —The abdom inal viscera
are occasionally protruded  through the
diaphragm,  either through some of the
natural apertures in this muscle, or defi
ciencies, or wounds, and lacerations in it.
The second kind of case is the most fre-
quent : Morgagni furnishes an instance of
the first.  Two cases, related by Dr. Ma-
cauley in Med.  Obs.  and Inq. Vol. 1.  and
two others published  by Mr. A. Cooper,
are instances ofthe second sort: and an-
other case has been lately recorded by the
latter-gentleman, affording an example of
the third kind.  Hildanus,  Pare,  Petit,
Schenck, &c. also mentions cases of phre-
nic hernia.  The disease  is quite out of
the reach of art.
   Mesenteric Hernia.—-If one of the layers
of the mesentery be torn by a blow, while
the other remains  in its natural state, the
intestines may insinuate themselves  into
tlie aperture and  form a kind of hernia 
94                                HERNIA.
 The same consequences may result from a
 natural deficiency in one of these layers.
 Mr. A. Cooper records a case, in which
 all the small  intestines, except the duo-
 denum, were  thus  circumstanced. The
 symptoms during life were unknown. (On
' Crural Hernia, &c. p.  82.)
   Mesocolic Hernia.—So named by Mr. A.
 Cooper, when the  bowels glide between
 the  layers of the  mesocolon   There  is a
 specimen of this disease preserved at St.
 Thomas's hospital.
   Every  surgeon should be aware, that
the  intestines may be strangulated within
the abdomen  from the  following causes :
1. Apertures in the omentum, mesentery,
or mesocolon, throngh which  the intestine
protrudes.  2. Adhesions, leaving an aper-
ture, in which a  piece of intestine  be-
comes confined. 3. Membranous bands at
the mouths of hernial sacs, which becom-
ing  elongated, by the frequent protrusion
and  return of the viscera, surround  the
intestine, so as to strangulate them within
the abdomen, when returned from the sac
(See A. Cooper on Crural Hernia, &c. p. 85.)
   Pott remarks;  that " Ruysch  gives an
account of an* impregnated uterus being
found on the outside of  the abdominal
opening; and so  do Hildanus and Sen-
nertus.  Ruysch also gives an account of
an entire spleen having passed the  tendon
ofthe oblique muscle.  And 1 have myself
seen the ovaria removed by incision, after
they had been some months in the groin."
(Vol 2.)
   The best sources of information on her-
nia are the following : Franco, Traite des
Hernies, &c; Lynn,  1561; Bvo. Littre, Ob-
servation sur une .Vouvelle Espece deher-
nie;  Mem. de I'Acad, des Sciences ; 1700.
Mevy; same work; 1701.  Littre, sur une
Hemic Rare; same work;- 1714. Muuchart
de Hernia incarcerate ; Tubing. 1722. Hei-
ster, Instit. Chirurg. et De Hernia  Incar-
cerate! Suppurata nonsemper lethali.Vogel,
abhandlung aller urten der bruche;  Lips.
1738. Peyronie, Observations, &c. sur la
Cure des Hernies avec  Gangrene,  Mem.
de I'Acad, de Chir. torn. 1.  Gunzius, Ob-
servationum Anatomico-chirurgicarum de
Herniis UbeUus; Idps.  1744:   Arnaud on
Hernias, 1748 ,• also his Mem.  de Chir.
Haller de Herniis Congenitis,  1749-   Ga-
rengeot, surplusieursHernies  singulieres;
Mem de I'Acad, de Chir. torn  2.  Moreau
sur les suites d'une Hernie operie ;  .Mem.
de I'Acud. de Chir. torn. 3.  Benevoli, una
Ernia assai particolare;  Firenzo,  1750.
Haller Hemiarum adnotationes; extant.
in  opnscul. pathol. 17.55.  Blanc JVouvelle
Methode d'operer les  Hernies,-  avec  un
essai sur les Hernies, par .11.  Hoin ; Or.
feg.nx) 1767;  8vo.  Lov.h, Reflexions *;/>
 VOperation dela Hernie; Mem.  del'Acad.
 de Chir. torn. 4.   Hoin, Essai sur les Her-
 nies rares et peu  connues;  1767.  Medi-
 cal Observations and Enquiries.  Pott's
 Works, vols. 2. and 3.  Goursaud  sm-  la
 Difference des Causes de Vetranglement
 des Hernies;  Mem. de VAcad. de Chir.
 torn. 4.  Le  Dran, Traite des Operations
 de Chir. et Observations de Chir. obs. 57.
 F. Hildanus,  cent. 5. obs. 54.  J. I,. Petit,
 Traite de  Mai Chir. torn.  2.   Sharp on
 the Operations, and his Critical Enquiry.
 Hertrandi Traite des Operations, et Ex-
 emple d'une Hernie formee  du cute droit
 par Vintestin ileum settlement,  dont une
 portion s'etoit echappee par une des echan-
 crures ischiatiques,  en se glissant sur les
 ligaments sacro-sciatiques ; Mem. de Chir.
 torn. 2.  Saltzmann, Disp. de  Vesicx Vri-
 narix Hernia ; 1712.  Mery sur des Be-
 scentes de la Vessie,- Acad,  de Sciences,
 1713.  J. L. Petit sur les  Hernies de la
 Vessie; Acad, des Sciences,  1717.   Ver-
 dier, Recherches sur la Hernie de la Ves-
 sie ; Mem. de I'Acad,  de Chir. torn.  2.
 Divoux, Disp.de Hernia Vesicx Urinaria;
 Argent. 1732.  Levret-, Obs. s«r la Hernie
 de la  Vessie; Mem. de I'Acad, de  Chir.
 torn. 2.  P. Petit (le jeune) sur les Her-
 nies de la Vessie, et de PEstomac;  Acad.
 de Chir. torn. 4.   Vater de Lienis Prolap-
 sione,- 1746.  Peyronie sur un  etrangle-
 ment de l'intestin,cause interieurement par
 Vadherence de Vepiploon au-dessus ded'an.
 neau;  Mem.de I'Acad, de Chir. torn.  1.
 Tenon in Acad, des Sciences,- 1764.  Gun-
 zius,  Obs. de Entero-epiplocele.  Callisen,
 System Chirurg.  hodiernx, pars posterior.
 Richter Von den Briichen, in 2 vols. 1778,
 1779.- or the French transl. by Rougemont.
 Also  Richter's Bibliothek, and Anfang.
 der Wundarzn.   Wilmer's Pract. Obs. on
 Hemix.   Schmucker's  Chir.  Wahrneh-
 mungen.  Desault's CEuvres Chirurg. par
 Bichat. torn. 2.   Hey's Pract.  Observ. in
 Surgery. Sandifort's Anat. Pathol.   Cam-
per's Demonstrat. Anat.  Pathol 1760;
 and his Icones Herniarum, edit, d  Soem-
 mering.  1801.  Dr. Hunter's Med.  Com-
 ment. 1762,1764.  Monro in Edinb. Med.
 Essays ;  and the edition of his  works by
 his Son.   Gimbernat's Account of a New
 Method of operating for Femoral Hernia.
 . 1. Cooper on Inguinaland Congenital Hernia;
 and  on  Crural  and Umbilical Hernia.
 Monro on Crural Hernia, 1803.  Sabatier;,
 Medecine Operatoire, torn. 1. Chopart and
 Desault,  Traite des Mai.  Chir.  Desault,
Parisian Surgical Journal.  Wrisberg in
 Comment.  Reg.  Societ. Gotting.  1778.
 Schmucker's  Vermischte  Chir. Schriften.
Holler's  Opera Minora,-  and  Dispula*
Hones Chir.   SuWerrde Memorie anatarnt- 
HERNIA.                                95
ro*clarurgiche di Antonio Scarpa,  1809
and 1810 ,• or tlie French transl. by Cayol,
1812.  Hicherand's Nosographie Chirur-
gicale, Tom: 3. p. 354, &c. Edit. 2.  Las-
sus,  Pathologie  Chirurgicale, Tom.  1,
p. 1, &c, Edit. 1809. Pelletdn Clinique
Chirurgicale, Tom. 3.  Travers on  Inju-
ries of the Intestines, &c. 1812. Leveilie,
.Youvelle Doctrine Chirurgicale,  Tom.  3,
p. 170, &c.  1812.    But, above all, the
work, which I feel infinite pleasure in re-
commending, from a conviction of its su-
perior  merit, and practical  utility, is  a
Treatise on Hernia by W. Lawrence ; Svo.
the first edit, of which was published 1807,
the second in 1810, under the title of a
Treatise on Ruptures.
   HERNIA CEREBRI.  (Fungus Cerebri.
Encephalocele.)   This name is given to a
tumour which every now and then  rises
from  the brain,  through  an ulcerated
opening in the dura mater, and protrudes
through a perforation  in  the cranium,
made by  the previous application of the
trephine.  Mr.  Abernethy has made  some
observations on this disease, and related
some cases.   In one of these, the hernia
cerebri arose  on  the tenth  day  after
trephining, and was as large as a pigeon's
egg; the  pia mater, covering it, was  in-
flamed -h and a turbid serum was discharg-
ed at the sides of the swelling, from be-
neath the dura mater.  On the eleventh1
day, the tumour was as large as  a hen's
egg, smooth, and ready to burst.  The
man died the  next day.   On examina-
tion, the swelling was found larger, than
before,  and of a dark colour, with  an  ir-
regularly granulated surface.  This ap-
pearance was owing to coagulated blood,
which adhered to its surface,  as the part
had bled so much, that the  patient's cap
was rendered quite stiff with blood.  The
pia mater was in general much inflamed,
and, as well as the dura mater, was defi-
cient at the  place  of the tumour.  The
deeper part  of the swelling  seemed  to
consist  of fibrous coagulated  blood, and
it was found to originate' about an inch
below the surface of the brain.
   Mr. Abernethy explains the particular
appearance and progress of the disease,
as follows:  " In consequence  of the
brain being  injured  to some depth be-
neath the surface,  disease of the vessels,
^nd consequent effusion  of the blood,
had ensued ;  the effusion was, for a time,
restrained by the superincumbent  brain
and its membranes ;  but, these gradually
yielding to the expansive  force exerted
from within,  and at last giving way alto-
gether, the  fluid  blood oozed  out and
congealed upon the  surface  of the  tu-
mour"   An  organized  fungus  could
hardly be produced so rapidly as these
tumours  are.  (Essay on  injuries of the
Head, p.  37.)
  Mr.  C. Bell contends,  however, that
such swellings are vascular and organized.
(Operative Surgery, Vol. 1.)
  When the bad symptoms disappear,  on
th« tumour  being no longer confined  by
the dura mater, it  is best to i.iterfcre as
little as possible, as the hemorrhage will
probably  cease, and the tumour drop  oft'
in pieces   (See  Edinb. Med.  Comment.
Vol.  I.p. 98. Med. Museum, Vol. 4. p. 463.)
The mildest dressings alone  should  be
employed, and all pressure avoided.
  When  the tumour acquires a very great
size, it may be pared off* with a kniie, as
Mr. Hill did several  times, with success.
(Cases in Stergery.)
  Should the  swelling still increase, and
bad symptoms prevail,  in consequence of
the  irritation and pressure on tlie brain,
the opening- in the  bone ought to ha en-
larged.  Were the bleeding to continue
in a dangerous degree, Mr.  Abernethy
suggests removing the  coagulum, to try
whether  exposure of  the cavity  would
stop  the effusion? of  blood.   Quesnay
mentions an instance, in which a patient
tore off"  the coagulum himself, and the
cavity healed up; Mem. ded'Acad. de Chir.
torn. 1.  The danger of applying styptics,
and irritating applications  is shewn  by
Hildanus, Obs. 14, and Mr. Hill, p. 198.
(See Abernethy on Injuries of the Head.)
  One would suppose,  that cases of this
kind would generally require the employ-
ment of every thing at all likely to keep
off,  and  diminish,  inflammation  of the
brain.
  [The American Editor has recently wit-
nessed the recovery of a patient with her-
nia cerebri—he does not venture to call it
a cure.—During the existence  of the  tu-
mour  vomiting  took  place, which was
followed by  a copious discharge of blood,
and an amelioration of the  symptoms.—
The patient, aged about 12 years, is now
in good health]
  HERNIA HUMORALIS.   (Inflamma-
tio Testis. Swelled Testicle.)  A very com-
mon symptom, attending a gonorrhea, is
a swelling of the testicle, which is only
sympathetic, and  not  venereal, because
the same symptoms follow every kind of
irritation on the urethra, whether pro-
duced by strictures, injections, or bougies
Such symptoms  are not similar to the  ac
tions arising from the  application  of ve-
nereal matter, for  suppuration  seldom
occurs, and when it does, the matter is
not  venereal.   The swelling and inflam-
mation appear suddenly, and as suddenly
disappear, or go from one testicle to the
other. The epididymis remains swelled, 
«6                                 HERNIA.
however,  even  for a considerable  time
afterwards.   (/. Hunter.)
  The first appearance of swelling is ge-
nerally a soft pulpy fulness of the body of
the testicle, which is tender to the touch;
this increases to a hard swelling, accom-
panied with considerable pain.  The epi-
didymis, towards  the  lower end of the
testicle,  is  generally  the hardest  part.
The  hardness  and  swelling,  however,
often pervade the* whole of the epididy-
mis.  The spermatic chord, and especi-
ally, the vas deferens, are often thickened
and sore to the touch.  The spermatic
veins sometimes become varicose.  A pain
in the loins, and sense of weakness there,
and, in the pelvis, are other casual symp-
toms.  Cholicky pains; uneasiness in the
stomach and bowels ;   flatulence;  sick-
ness ;  and even vomiting; are not unfre-
quent.  The whole  testicle is  swelled,
and not  merely the epididymis, as has
been asserted.   (J. Hunter.)
  The inflammation of the part most pro-
bably arises from its sympathizing with the
urethra.   The  swelling of the  testicle
coming on, either  removes the pain in
making  water,  and suspends   the dis-
charge, which  do  not  return,  till  such
swelling begins to subside; or else the
irritation in the urethra, first ceasing, pro-
duces a swelling of the testicle,  which
continues till the pain and discharge  re-
turn ;  thus  rendering it doubtful, which
is the cause, and which the effect.  Occa-
sionally,  however, the  discharge has  be-
come  more violent, though the  testicle
has swelled; and such swelling has even
been known to occur after the discharge
has ceased;  yet, the latter  has returned
with  violence,  and  remained as long as
the hernia humoralis.  (/. Hunter.)
  Irritation at the mouth of the vasa de-
ferentia has been mentione d as  a cause ;
but,  were this true, both testicles would
usually be affected at the same time, and
the complaint would occur more frequent-
ly,  when  the irritation  of  the  urethra
extends  far towards the bladder, than
when it only reaches about an inch  and a
halt; or two inches, from the orifice ofthe
passage.   (/. Hunter.)
  Hernia humoralis, with  stoppage of
the discharge, is apt to be attended with
strangury.   A  very singular  thing is,
that  the  inflammation more  frequently
comes on when  the irritation in the ure-
thra  is going off,  than when it is at its
height. (J. Hunter.)
  The enlargements ofthe testicle, from
rancer and scrophula, are generally slow in
their progress -, that of a hernia humoralis
very quick. (J.  Hunter.')
  Rest is the best remedy, and  the hori-
zontal position ofthe body is easiest. \.t
all events, the testicle must be well su»«
pended;  to which expedient the  patient
will readily have  recourse as soon as he
knows the ease it affords.  The case  is
treated as inflammation in general, by
bleeding and purging, and applying fo-
mentations and poultices."  Leeches have
often proved  serviceable.  The swelling
not being venereal,  mercury is only  use-
ful in removing the induration,  continuing
after  the  inflammation  has  subsided.
Vomits have  been  recommended,  and
found  beneficial.  They  have  even been
known to cure the complaint in a siirpri-
singly sudden manner.  Opiates are use-
ful.  When  suppuration occurs, no mer-
cury  is requisite,  only  common  treat-
ment.
  As the hernia humoralis often appears
to depend on  the cessation of the  dis-
charge, some  (Bromfield) have  advised
irritating the urethra with  bougies to
bring on the gonorrhoea again;  but the
practice  is not followed by the expected
good.  The introduction of venereal mat-
ter into the urethra has also been most ab-
surdly suggested.
  A hernia humoralis is at first very quick
in subsiding; but, some of the swelling
remains a long while, and the hardness
and swelling of" the epididymis even con-
tinue for years, nay,  for life.  However,
no inconvenience attends the mere indu-
ration. In such instances, the vas deferens
may occasionally be rendered impervious,
though the  occurrence must  be  by no
means frequent. (J. Hunter.)
  Frictions with camphorated mercuri-
al ointment;  fumigations with aromatic
herbs ; and electricity ; arethe  best means
for promoting the absorption ofthe super-
fluous particles, causing the induration in
question.  (J. Hunter.)
  The signs, distinguishing a hernia hu-
moralis from a scrotal rupture, are ex-
plained in the article Hernia.
  John Hunter has  undoubtedly given
the best account of hernia humoralis.
  HERPES, (from i$na, to creep.)   Se-
veral cutaneous,  superficial kinds of ul-
cerations, having a  great propensity  to
creep, or spread over the skin,  are  so
named.  Cullen places this disease in the
class  locales, and order dyalyses ;  and de-
fines it, phlyctenae,  or a great number of
small ulcers, crowding together, creeping,
and difficult to heal.  For  an  account of
one disease, usually  considered as a spe-
cies of herpes, see Noli me tangere. Refer
also to Tinea  Capitis, which some have
classed with herpes.
   The tetter, ring-worm, serpigo, or darta,
consists of clusters  of sharp-pointed pus-
tules, of a yellowish white colour,  with
inflamed bases.  The di-ense  is atter^td 
                  II OR

Svith more or less smarting and itching,
is  sometimes difficult of cure, and apt to
recur.   When the disorder is connected
with constitutional causes,  small doses of*
mercury are useful.  One of the best local
applications, is a solution  of the hydrar-
gyrus muriatus in lime-water.
  Shingles, zona aurea, or herpes zoster, is
a disease, which appears in large clusters
on the neck, breast, loins, hips, or thighs,
and sometimes spreads all round the body,
or limbs.  The heads of the little pustules
have  at first a white watery appearance,
and then a small round scab, resembling
a  millet-seed.  .Hence the names  herpes
miliaris.  The complaint is often attended
with  febrile symptoms   The treatment
should  resemble that of erysipelas;  but,
bark and camphor are particularly recom-
mended as useful internal medicines.  The
lotion of lime-water,  and muriated mer-
cury is also said to be frequently an effica-
cious application. Old persons are subject
to a more inveterate, obstinate, and dan-
  fsrous species of shingles. All the other
  inds of herpes, enumerated by writers,
are medical cases, as, indeed, some may
consider the two latter affections: we shall
therefore, not  enlarge on the  subject in
this work.
   HORDEOLUM, (dim. of hordeum, bar-
ley.)  A  little  tumour on the eye-lid,
resembling  a barley-corn.  A  Stye.  As
Scarpa  remarks, the stye is strictly only a
little boil, which projects  from the edge
of the  eye-lids,  particularly  often  near
the great angle  of the eye.  This little
tumour, like the f'urunculus, is of  a dark
red colour,  much inflamed, and a great
deal more painful, than might be expect-
ed, considering its small size.  The latter
circumstance is partly owing to the vehe-
mence of the inflammation producing the
stye, and partly to the exquisite sensibi-
lity and tension of the skin, which covers
the edge of the eyelids.  On this account,
the  hordeolum very  often  excites fever
 and restlessness in delicate, irritable con-
 stitutions;  it suppurates slowly and im-
 perfectly ; and, when suppurated, has no
 tendency to burst.
   'I'iie  stye,  like other  fVrunculous in-
 flammations,  forms an exception  to the
 general rule, that the best mode, in which
 inflammatory swellings can end,  is reso-
 lution.   For,  whenever, a furunculous in-
 flammation extends  so deeply as  to de-
 stroy  any of"  the cellular substance, the
 little tumour  can never  be' resolved, or
 onh imperfectly so.  This event,  indeed,
 woiild  rather be  hurtful,  since there
 would  still remain behind a greater or
 smaller portion of dead cellular mem-
 hra.ie,  which, sooner or later, might bring
 on a renewal ofthe stve in the same place
     Vol. II.
                HOB               9P

as before, or else become inverted into a
hard indolent body, deforming the edge
ofthe eyelid.
  The resolution of the incipient  hor-
deolum may  be effected in that stage of
it, in which the inflammation only inte-
rests the  skin, and not the cellular sub-
stance underneath, as is the case  on the
first appearance of the disease.   Now
repellent, cold  applications  are  useful;
particularly  ice.  But when the  hordeo-
lum has affected, and destroyed,  any of
the cellular membrane underneath, every
topical repellent application is absolutely
useless, and even hurtful;  and the  pa-
tient  should have recourse to emollient
anodyne  remedies.  The hordeolum and
eyelids  should  be  covered  with a warm
soft bread and milk poultice, which ought
to be renewed very often. When a white
'point makes its appearance on  the apex of
the little tumour, Scarpa says, the sur-
geon should not be in a hurry to  let out
the  small quantity  of serous  matter,
which exists between the skin and dead
portion of cellular membrane.  It is bet-
ter, that  he  should wait till the skin,
within this white point,  has  become still
somewhat thinner, so as to burst of itself,
and give  a ready vent, not merely to the
little serous  matter, but, to all  the dead
cellular membrane, which constitutes the
chief part of the disease. When the con-
tents of  the little tumour  are slow in
making  their way outward, through the
opening,  the surgeon, gently compressing
the base of the stye,  ought to force them
out.  After this, all the symptoms of the
disease  will disappear, and  the  cavity,
left by the  dead  cellular membrane, in
tlie centre of the little tumour,  will be
found quite  filled up, and healed, in the
course of twenty-four huurs.
   Sometimes,  though seldom, this pro-
cess  of  nature, destined to  detach the
dead from the living cellular membrane,
 only  takes  place incompletely,  and  a
 small fragment of yellow dead cellular
 substance still  continues fixed in the ca-
 vity , and hinders the cure.   In  this  cir-
 cumstance,  the further employment of
 emollient poultices is of little or no ser-
 vice.  The surgeon should dip the point
 of a camel-hair pencil in sulphuric acid,
 and touch the inside of the stye with it,
 one or more times, until the sloughy cel-
 lular membrane comes away.  After this.
 the small cavity remaining will soon close.
 Should the  eyelid continue afterwards a
 little swollen and edematous, this affec-
 tion  may be  removed  by  applying the
 lotio aquae  litharg.  acet.,  containing a
 little spirit of wine.  Some  persons are
 very often  annoyed with  this   disease-
 Scarpa imputes this most frequently to a 
98           HYL)
II Y1)
disordered state of the primx vix, often
met with in persons who live  on acrid ir-
ritating food, and drink too much spirits.
(See Scarpa suite  Mnlattie degli Occhi,
cap. 2)
  HYDARTHRUS. (from vd»pt  water,
and «?^ov,  ajoint.) The white swelling.
(See Joint a.  )
 "HYDRARGYRIA.  A  peculiar erup-
tion  occasioned by the use of mercury.
(See Mercury.)
  HYDRARGYRUS. (from vbttp, water,
and «fyt>f«s, silver.)  Quicksilver;  mer-
cury.  (See Mercury.)
  HYDROCELE, (from vfrap, water, and
kjjAjj, a tumour.)  The term  hydrocele, if
used in a literal sense, means  an>  tumour
produced by water; but  surgeons  have
always confined it to those,  which pos-
sess either the membranes of the scrotum^
or the coats of the testicle and its  vessels.
The first of these, viz. that which has its
seat in the membranes ofthe scrotum,  is
common to the whole bag, and to all the
cellular substance, which loosely enve-
lopes both the testes. It is, strictly speak-
ing,  only a  symptom of a  disease,  in
which the wh61e habit is most frequently
more or less concerned, and very  seldom
affects this part  only.   The latter,  or
those which  occupy the coats  immedi-
ately investing the testicle and its vessels,
are absolutely  local, very seldom affect
the common  membrane of the scrotum,
generally attack one side only;  and are
frequently found in persons, who are per-
fectly free from all other complaints.
  Dr.  Monro,  the father, professor  of
anatomy  at Edinburgh, and  Mr.  Samuel
Sharpe, were almost the only writers,
before Mr. Pott, who sensibly awl ration-
ally  explained the true  nature of  these
diseases.

   AXASARCOUS TUMOUR OF THE SCROTUM.

  It is most frequently only  a symptom
of a  dropsical habit, and very often  ac-
companies both the general anasarca, and
the particular  collection  within  the  ab-
domen, called  the ascites.   This being
the case,  and the  true method  of cure
consisting in an internal medical process,
it has been improperly ranked among the
species of hydrocele, though  the nature
of the contents will certainly admit the
use ofthe word.
  " It is (says Pott) an  equal, soft  tu-
mour, possessing every part of the cellu-
lar membrane, in which both the testicles
are enveloped, and consequently is gene-
rally as large on one side as on the other;
it leaves  the skin  of its natural colour;
oi'j  to speak  more properly,  it does not
 redden or  inflame it;  if the  quantity of
 water be  not  large, nor the  detention
 gieat, the skin preserves some degree of
 rugosity :  the tumour has a doughy kind
 of  feel: easily receives, and for  a while
 retains, tiie  impression of the  fingers;
 tlie raphe, or  seam, of the  serotum di-
 vides  the swelling nearly equally; the
 spermatic  process is j>erfectly free, and of
 its natural size;  and the testicles seem to
' be in the middle of the loaded membrane.
 This  is the appearance, when the  dis-
 ease is in a moderate degree.   But if tlie
 quantity of extravasated serum be large,
 or the disease farther advanced, the skin,
 instead  of being  wrinkled,  is  smooth,
 tense, and plainly shews# the limped state
 of the fluid underneath :* it is cold to the
 touch, does not so long retain the impres-
 sion of the finger,  and  is always  accom-
 panied with a similar distention of the
 skin of the penis; the preputium of which
 is sometimes  so  enlarged, and so twist-
 ed, and distorted, as to  make a very
 disagreeable appearance.  These  are the
 local symptoms : to which it may be add-
 ed, that a yellow countenance, a loss of
 appetite, a deficiency  of urinary  secre-
 tion, swelled legs, a hard belly,  and mu-
 cous stools, are  its very frequent compa-
 nions.
   " The  cure of the  original   disease
 comes within the province  of the  physi-
 cian,  and  requires a  course of internal
 medicine : but sometimes.the loaded scro-
 tum and penis are so troublesome to the
 patient, and in such danger of mortifica-
 tion, that a  reduction of their  size be-
 comes absolutely necessary; and at other
 times a derivation, or  discharge,  of the
 redundant extravasated serum from  this
 part is ordered as an assistant to the in-
 ternal regimen.
    " The chirurgical means in use for this
 end is called  in general scarification; a
 term,  whose  precise  sense  has  by no
 means been settled ;  by which it has now
 and then  happened, that a general order
 being given,  and  che particular  method
 of executing it being left to the choice of
 those who have  not been  sufficiently ac-
 quainted  with  this  kind  of business,
 much hazard has been incurred,  and con-
 siderable mischief done, which might have
 been avoided.
    " The means of making this discharge
 are two,  viz. ptmctiire and  incision: the
 former is made with the point of a lancet;
 the latter with the same instrument, or
 with a knife.
    "The  generality  of writers   on  this
 subject have spoken on the two methods
 in  such  a manner,  that  a practitioner,
 who had  seen but little of either, woul«°.
 be inclined to  think,  that it was  a n»at'.i\ 
HYDROCELE.                               99
of great indifference, which we should
make use  of: and  that the safety  and
utility of each were equal: which is by no
means the case
  " The intention of the use of either is,
by a discharge of extravasated serum, to
alleviate the present  uneasiness; and, by
reducing the size ofthe scrotum, t<» render
it le^s  troublesome, and less  likely to
mortify.  In some few  instance,  it has
indeed  happened  that   this drain  has
provad a radical cure of the  original  dis-
ease ; but that has been  accidental,  and
is not in general  to  be expected.  The
intention is  generally palliative;  and, if
the patient lives, is most likely to require
repetition:   therefore,  if there be  any
difference between the two methods, with
regard either to ease or safety,  there can
be no doubt which ought to be preferred.
  " All wounds of membranous parts, in
anasarcous or dropsical habits, are neces-
sarily both  painful and  hazardous; they
are apt to  inflame,  are very difficultly
brought to suppuration, and will often
prove  gangrenous in spite of all endea-
vours to the contrary.   But the  larger
and  deeper tlie  wounds are, the more
probable are  these  bad consequences.
Simple  punctures, with the  point of a
lancet, are much less  liable to be attended
by them, than any other kind of wound ;
they generally leave  the skin easy, soft,
cool, uninflamed,  and in a state to admit
a repetition of  the same operation,  if
necessary.   Incisions create a • painful,
crude, hazardous sore, requiring constant
care  Punctures seldom produce any un-
easiness at all; and stand in  need of only
a superficial pledget, for dressing.
  " Now, although there is  so very ma-
terial a difference in  the symptoms  and
trouble attending the two methods, yet is
there none in their effect: the communi-
cation ofthe cells of the dartos  with each
other is so free, through every part of it,
that punctures made  with the fine point
of a bleeding-lancet,  into the  most  super-
ficial of them, will,  as  certainly  and as
freely,  drain oft'all the water, as a large
incision,  without any  of its inconveni-
ences or its hazard.   Neither the  one
nor the  other will cure  the  original  dis-
ease, unless by mere accident: they are
both made, with a design to cure only .the
focal one.   The same habit and constitu-
tion  remaining, the  same effect will in
general follow, and  the same  relief be
again necessary.   The ease,  the freedom
from bad symptoms,  or from danger,  and
the state  iu which  the parts are left,
render  one  method practicable   at  all
times,  and capable of being  repeated as
often as may be  thought necessary: the
fatigue, pain,  confinement and Hazard,
 which most frequently attend the other,
 make one experiment in general as much
 as most people choose  to submit to, or in-
 deed have an opportunity  of complying
 with."
   Mr.  Pott afterwards remarks;  " If we
 consider tlie preceding complaint as mere-
 ly symptomatic, and do not rank itfamong
 the different kinds of  hydrocele, there
 will then remain only three, viz.
   " 1.  That which consists of a  collec-
 tion of water in the cells  of the tunica
 communis, or cellular membrane, enve-
 loping  and connecting the spermatic ves-
 sels.
   " 2.  That which is  formed by  tlie ex-
 travasation of a fluid, in the same coat
 as the former, but which, instead of being
 diffused through   the  general  cellular
 structure of it, is confined to one cavity
 or cyst, in which all the water constitut-
 ing this species of disease  is contained ;
 the rest of the membrane being in its na-
 tural state.
   " 3.  That which is produced by the ac-
 cumulation of a quantity of water, in the
 cavity ofthe tunica vaginalis testis.
   "These three are distinct, local,  and
 truly within  the  province  Qf surgery.
 They may  accidentally be combined or
 connected with other  disorders, but not
 necessarily; and are frequently found in
 persons whose general habit is good, and
 who are perfectly free  from all other com-
^plaints."

 THE HTDUOCELE OF THE CEIXS OF THE TUNI-
              CA COMMUNIS.

   " The spermatic vessels from their ori-
 gin quite down to the insertion  into the
 testicle, are enveloped in, and connected
 together by, a membrane, called formerly
 tunica  vaginalis vasorum spermaticorum,
 but now (more properly) tunica commu-
 nis.  This membrane, so enveloping the
 spermatic vessels,  has no one particular
 cavity, (as its old  name  would seem to
 imply;) but is merely cellular, as either
 the Inflation of air or the  extravasation
 of a fluid, will always prove   While  it
 is within the cavity of the belly, its cells
 are lax and large;  and when  it has pass-
 ed out  from thence, and has formed a part
 of the  spermatic process, by enveloping
 its  vessels,  its cells are rather smaller,
 and  the  membrane  composing  them,
 firmer. It is included  within  that thin
 expansion of muscular fibres, called  the
 cremaster.   And a great number  of lym-
 phatics, passing from  the testicle to the
 receptaculum chyli,  are always  to be
 found in it.
   " An attentive consideration of these
 cireumstances in the structure of this part 
100                            HYDROCELE
will shew us, (continues Pott) why either
obstruction  or breach of the lymphatic
vessels, considerable pressure by  means
of diseased  indurations within the abdo-
men, or a morbid state ofthe parts which
should receive the lymph from the vessels
ofthe spermatic cord, may induce the dis-
ease in question; and also, when it  is
produced, that  its  appearance,  and the
nature of the  extravasation, must make
the term cellular a very proper one, as ex-
pressive of its true state.
  " When the disease is simple,  it is per-
fectly local; that is, it is confined entire-,
ly to the  membrane forming the  tunica
communis; and does not at all affect, either
the scrotum, the tunica vaginalis  testis, or
any other part."
  According to  Pott, it does not give a
great deal of trouble,  unless it arrives to
a considerable size;  and, being  by  no
means so frequent as either  of the other
two kinds  of hydrocele,   it is in ge-
ner..l  but little known or  attended  to.
With some, it passes  for a varix of the
spermatic cord; with others, for the de-
scent of a  portion  of omentum, which,
having contracted an adhesion, cannot be
returned.  Thus, its true nature not being
in general rightly'understood, and  it giv-
ing but little trouble or uneasiness while
it is within moderate bounds, and neither
hindering any necessary action or faculty,
they who have it are most frequently ad-
vised to be  contented with  a suspensory
bandage, and find very little inconvenience
from it.
  " Sometimes it arises to so large a size,
and gets into such a state,  as to become
an object of surgery,  and  to require our
very serious attention.
  " In general, (says Pott,) while it is of
moderate size,  the  state of it is as fol-
lows.   The  scrotal bag  is free  from  all
appearance of disease; except that when
J he skin is not corrugated, it seems rather
 iller,  and hangs rather  lower  on that
side than on the other, and if suspended
lightly on the  palm of the  hand,  feels
heavier:  the testicle, with its epididymis,
is to be felt  perfectly distinct below this
fulness, neither enlarged, nor in any man-
ner altered  from its  natural state: the
spermatic process is considerably  larger
than it ought to be, and feels like a varix,
or like an omental  hernia,  according to
the different size ofthe tumour;  it has a
pyramidal kind of form, broader at the
bottom than at the top: by gentle and
continued pressure it  seems gradually to
recede or go  up, but drops down again
immediately upon removing the pressure,
and that as  freely in  a supine,  as in an
erect, posture; it is attended with  a very '
gmall degree of pam or uneasiness ;  which
uneasiness  is not felt  in  the scrotum,
where the tumefaction is, but in the loins
  " If the  extravasation be confined  to
what is called the spermatic process, the
opening in the tendon of the abdominal
muscle is not at all dilated,  and the pro-
cess passing through it  may be very dis-
tinctly fell; but if the cellular membrane,
which invests  the speimatic vessels with-
in the abdomen, be affected,  the tendin-
ous aperture  is  enlarged;  and the in-
creased size of the distended membrane
passing through it, produces to the touch,
a sensation, not  very  unlike  that  of an
omental rupture.
  " While it is small, it is hardly an ob-
ject of surgery-; the  pain  or inconveni-
ence  which it produces being  so little,
that few people would chuse to submit to
an operation to get rid of it; and it  is
very  seldom   radically cured without
one:  but when  it is large  or  affects the
membrane within the  cavity, as well as
without, it becomes an apparent deformi-
ty, is very inconvenient both  from size
and weight,  and the only method of cure
which it admits is far from being void  of
hazard.  The plan  is to make a free in-
cision into the  swelling."   (See Pott on
Hydrocele.)

THE ENCYSTED  HYDROCELE OP  THE TUNICA
               COMMUNIS.

  "This species of hydrocele (Pott re-
marks) has its seat in the same part as the
preceding,  viz. the tunica communis^, or
cellular membrane, which  invests the
spermatic vessels; with this difference,
that, in the former, the water is diffused
in general through all  the cells  of the
membrane;  whereas,  in this, it is con-
tained in one cavity only.  If any  of the
three  kinds  of hydrocele  deserves the
name  of encysted, it is this.   The water,
which constitutes it, being all contained
in a bag,  formed in the same manner as
all the coats of all encysted tumours are,
viz. by  mere  pressure  and condensation
of the common membrane.
  " It is a complaint by no means infre-
quent, especially  in  children.   It was
very well known to many ofthe  ancients,
and has been very accurately described
by Albucasis,  Celsus,  Paulus, JEgineta,
&c.; but  later writers have often mista-
ken it for, and represented  it as, a species
of wind-rupture,  or  pneumatocele;   a
disease  existing in  their  imaginations
only.  It most  frequently  possesses the
middle part of the process,  between the
testicle and groin, and is generally of an
oblong figure; whence it has by  some
people been compared to an egg, by others
t'i a fi-h's  bladder.  Whether it be large 
HYDROCELE.                             101
or small, it is generally pretty tense,  and
consequently the fluctuation of the water
within  it,  not  always  immediately or
easily  perceptible; for  which  reason  it
has been supposed to  contain air only.
It gives  no  pain, nor (unless it  be very
Urge indeed) does it hinder any necessa-
ry action. It is perfectly circumscribed ;
and  has  no communication, either with
the cavity of the belly above, or that  of
tie vaginal coat of the testicle below it.
The testis and  its epididymis, avc  per-
fectly and distinctly to be felt  below the
tumour,  and are absolutely independent
of it.  The  upper part of the spermatic
process  in the groin  is  most frequently
very distinguishable.  The swelling does
not  retain the impression of the fin: ers;
and when lightly struck upon, sounds as
if it contained wind only.' It  undergoes
no. alteration from change of the patient's
posture ; nor is affected by his coughing,
sneezing, &c. and has  no  effect on  the
 discharge per anum.
   " These  marks (while the  disease is
 simple and  uncombined with  any other)
 are sufficient to distinguish it by, from all
 others which may affect the same part;
 but it sometimes happens, that  the pre-
 sent complaint is found connected either
 with a true hernia, or  with  a hydrocele
 of the  tunica vaginalis; by  which  the
 case is  rendered complex, and less easy
 to be understood.
   " In this, as in every other case where,
 from a complication of symptoms and ap-
 pearances,  a combination of diseases may
 be suspected, there is but one method of
 investigating the truth ; which is, to con-
 sider carefully  what disorders  the part
 aggrieved  is naturally liable  to;  what
«t,hc distinct symptoms and appearances of
 t ucli of those are ; and what are the effects
 of the  present  complaint.  The two dis-
 eases with which this kind of hydrocele
  is most likely to be combined are, an  hy-
 drocele of the tunica vaginalis testis, and,
 a true hernia; the parts within the groin,
  the spermatic process, and  the scrotum
  being the seat of all three.
   " One mark,  or characteristic  of an hy-
  drocele of the tunica vaginalis  testis is,
  that, it possesses and distends the inferior
  part of the scrotum ; and that the testicle
  being nearly (though not absolutely) sur-
  rounded by the water, it very seldom hap-
  pens, that the  former can be clearly and
  plainly  distinguished by the fingers of an
  examiner ;  whereas, in the encysted col-
  lection, in the membranes of the cord, the
  tumour is  always  above the  testicle,
  which is obvious and plain to be felt be-
  low it.
    " A nother circumstance worth attend-
 •ing to  is,  that although the fluid in a hy-
drocele ofthe vaginal coat does so nearly
surround the testis as to render it often
not very easy to be distinguished, yet the
different parts of the tumour have always
a very different  feel: for  instance, in all
those points  where the vaginal tunic  is
loose, and unconnected with the tunica
albuginea, the tumour is  soft and  com-
pressible, and  gives a clear idea of the
contained fluid; but when these two coats
are continuous, or make one and the same
membrane, and have  no cavity between
them (which is the case on the middle and
posterior part) there will always be found
a hardness and  firmness very unlike  to
what is to be found in  all those places,
where the distance between the two  tu-
nics  leaves room for the  collection of a
fluid .- now the hydrocele of the cord be-
ing formed in the mere cellular membrane
of it, is the  same to the  touch in all the
parts  of the tumour,  and feels like  a
distended bladder through  every  point
of it.
   " The free state of the upper  part of
the spermatic  process, while the tumour
is  forming below ; the gradual accumu-
lation of the fluid,  and consequently  the
gradual growth of the swelling; the in-
dolent  and  unaltering state of it;   its
being incapable of reduction, or  return
 into the  belly from the first; its  being
always unaffected by the  patients cough-
ing, or sneezing; and the uninterrupted
freedom of the fecal discharge per anum,
will always distinguish it  from an intes-
 tinal hernia; and he who mistakes it for
 an omental one, must be very ignorant, or
 very heedless.
   " Now, although there may not always
 be such external  marks as may, to  the
 eye, explain the combination of these dis-
 eases with each other;  yet the particular
 seat and  symptom of each being known,
 and the sensations which  they produce to
 the fingers  of an  intelligent examiner
 being well understood, when such mixed
 characteristics are found in the same sub-
 ject, we may reasonably conclude the case
 to be complex, and act accordingly.
    " I have indeed seen an encysted hy-
 drocele,situated so high toward the groin,
 as to render the perception of the sper-
 matic  vessels very obscure, or even  im-
 practicable ; but  then, the state and ap-
 pearance of the testicle,  and the absence
 of every symptom proceeding from con-
 finement of the 'intestinal canal, were suf-
 ficient marks of the true nature of  the
 complaint.
    " Infants are much more subject to this
  disease than adults; though it  often af-
  fects the latter.
    « In young children, it frequently dis--
  sipates in a short time,  especially if as 
102        "                   HYDROCELE
 sisted by warm fomentation, and an open
 belly.
   " If it does not disperse, that is, if it
 be not absorbed, the point of a lancet will
 give discharge to  the  water;  and,  in
 young children, will most frequently pro-
 duce a cure:  but in adults, the cyst form-
 ed by the pressure of the fluid does some-
 times become so thick, as to require divi-
 sion  through its  whole length; which
 operation may  in general be performed
 with great ease, and perfect safety."  Mr.
 Pott says,  in  general, because it is most
 frequently  so : though he has  seen  even
 this, slight as it may seem, prove trouble-
 some, hazardous, and fatal.  (See Pott on
 Hydrocele.)
   Sir James  Earle has proposed  curing
 this case, in  the same way as the hydro-
 cele of the tunica vaginalis, viz. by an in-
 jection  of red  wine and  water.  This
 gentleman has succeeded in this manner
 himself.  (See  Earle  on Hydrocele, p. 194,
 edit. 2.)

  HYDROCELE  OF  THE  TUNICA VAGINALIS
                TESTIS.

   " The third species of this disease, (as
 Pott describes)  is that which is confined
 to the vaginal coat, or bag, which loosely
 envelopes  the  testicle.    In  a natural,
 healthy state, its cavity always contains a
 small quantity  of a  fine fluid, exhaled
 from capillary  arteries, and  constantly
 absorbed by vessels appointed  for  that
 purpose.
   " This fluid, in the natural small quan-
 tity,  serves to keep  the  tunica albuginea
 moist, and to prevent a cohesion between
 it and  the  vaginalis;  a consequence,
 which almost necessarily follows any such
 diseased state of these parts, as prevents
 the due secretion of it.  On the contrary,
 if the quantity deposited be  too large, or
 if the regular absorption of it be by any
 means prevented, it will be gradually ac-
 cumulated, and, by  distending the  con-
 taining bag, will form the disease m ques-
 tion."
   It is a disease from which  no time of
 life is exempt; not only adults  are  sub-
ject to  it,  but young children are  fre-
 quently'afflicted with  it;  and infants
 sometimes born with it.  What is the im-
 mediately producing cause, Mr. Pott will
 not take upon  him to  affirm.   Ruysch
 is of opinion, that  it proceeds from a va-
 ricose state   of  the spermatic vessels.
 What real  foundation there may be for
 such  conjecture, Mr. Pott  cannot say;
 certain it is, that the spermatic vessels are
 very frequently  found varicose,  in  per.
 sons afflicted with this kind of hydrocele ;
 hut  whether such state of these parts
 ought to be regarded as a cause, or as an
 effect of  the  disease, is a matter  worth
 enquirirg into.
   " In Morgagni,  are  some observations
 on the state of the parts concerned, parti-
 cularly the inside of the tunica vaginalis,
 and outside of the albuginea; which, if
 repeated and confirmed, may possibly lead
 us on to farther information.
   " Whatever tends  to  increase the se-
 cretion of the fluid into the sacculus, be-
 yond the due and necessary quantity, or
 to prevent its being taken up, and carried
 oft,  by the proper absorbent vessels, must
 contribute to its production ;  which is *o
 slow, and gradual, and at the same time
 so  void  of pain,  that  the patient sel-
 dom attends to • it, until  it has arrived to
 some size.  Not but that it* sometimes is
 produced very suddenly; and in a very
 short space  of time attains considerable .
 magnitude.
   " The size  and figure of the tumour
 (continues Pott) are various in  different
 people, and under different circumstances.
 In general, at its first beginning,  it is ra-
 ther round;  but  as it  increases, it fie-
 quently assumes a pyriform  kind  of fi.
 gure, with its larger extremity downward:
 sometimes it is hard, and almost  incom-
 pressible ; so much so, that,  in some few
 instances, it has been mistaken for an in-
 duration of the  testicle: at other times,
 it is so soft and lax, that both the testicle,
 and the fluid surrounding it, are  easily
 discoverable.  It is perfectly  indolent, in
 itself; though its weight does sometimes
 produce some small degree of uneasiness
 in the back.  The transparency of  the
 tumour, the great characteristic  (as it is
 called) of this disease, and on which al-
 most all writers  have agreed to  lay  the-
 greatest stress, and to rest their proof of
 the nature of the disorder, is, according
 to Pott, the most fallible, and uncertain
 sign belonging it: it  is a circumstance
 whieh does not depend upon the quantity,
colour, or consistence of the  fluid consti-
 tuting the disease, so much as on the un-
certain thickness, or thinness of the con-
taining bag,  and of the  common  mem-
branes of the scrotum.
  " If (adds this celebrated writer) they
are thin,  the fluid limpid, and the accu-
mulation made so quick as not to give the
tunica vaginalis time  to thicken  much,
 the rays of light may sometimes be seen
 to pass through  the tumour: but this is
 accidental, and by no means to be depend-
ed upon.  Whoever would be acquainted
 with  this disorder, must learn to distin-
 guish it by other, and those more certain
 marks; or he will be apt to fall into very
 disgraceful, as well as pernicious  blun-
 ders. The colour of the fluid is very dif- 
HYDROCELE.                            103-
.fcrent and uncertain; sometimes it is of
 a pale yellow, or  straw-colour;  some-
 times it i-> inclined to a greenish cast; some-
 times it is dark, turbid; and bloody ;  and
 sometimes it is perfectly thin and limped-
   " In the  beginning of the disease,  if
.the water be accumulated slowly, and the
 tunica vaginalis thin and lax, the testicle
 may easily be perceived ;  but if the said
 tunic be firm,  or the water accumulated
 in  any considerable quantity, the  testis
 cannot be felt at all;  and  other  symp-
 toms, or marks must be attended to.  In
 most cases, the spermatic vessels may be
 distinctly felt  at their exit from the ab-
 dominal muscle, or in the groin ;  which
 will  always  distinguish  this  complaint
 from  an intestinal hernia,  the disease
 which it is most likely to be confounded
 with.  It does indeed now and then hap-
 pen, that the vaginal coat is distended so
 high, and is  so full, that it is  extremely
 difficult,  nay, almost impossible, to feel
 the spermatic process: and it also  some-
 times happens, that the same kind of" ob-
 scurity is occasioned by the addition of
 an encysted  collection of water  in the
 membrane of the cord; or by  the case
 being combined with a true enterocele.
 These circumstances are  not  very fre-
 quent, but yet do occur often enough to
 render it  well worth While to mention
 them; and to signify that, when they are
 met with,  recourse  must be had to other
 marks.
   " The two coats of the testicle, the tu-
 nica vaginalis  and tunica  albuginea, are
 so inseparably united at the   posterior
 and superior, or rather the posterior and
 middle part of the  tumour,  that no fluid
 can collect between them ; and, in  opera-
 ting, a puncture, or incision, made here,
 cannot only   do  no service, as it cannot
 reach the water, but must injure the tes-
 ticle, or epididymis, and do  great mis-
 chief.
   " This natural connexion,  between the
 two tunics, at the upper and hinder part,
 is the reason (says Pott) why, in a simple
 hydrocele, that part of the tumour feels
 so very unlike to every other.   In that,
 the tunica albuginea, and vaginalis,  being
 immediately  continuous, no water can get
 between them ; and therefore, the fingers
 of an intelligent examiner must immedi-
 ately discover the firmness and hardness
 arising from  the  union of these  parts:
 in all others,  the  two membranes  being
 unconnected, and affording  a void space
 for the collection  of water,  the fluctu-
 ation of it will always be distinguishable.
   " This must for ever discriminate the
 simple hydrocele of the tunica  vaginalis,
 from the amis^-cous swelling of the scro-
 ti'.!!);  from the encysted hydrocele  of the
 cord;  and from   the  intestinal hernia.
 The first is every where equal, tumid and
 soft; and every" where equally receives
 and retains the impression of the fingers :
 the second,  though circumscribed,  uot
 very compressible,  and affording the sen-
 sation of fluctuation, yet does not pit, and
 is alike to the touch in all parts of it: and
 in the third,  if the testicle be distinguish-
 able at all, it is found at the inferior part
 of the whole tumour.
   ." An  indurated  or  scirrhous testicle
 (continues this author) /has indeed, very
 frequently, a quantity of fluid lodged in
 its vaginal coat  (hydro-sarcocele;)  which
 is a  circumstance  (says  Pott) not to be
 wondered at; the  diseased state  of th«
 gland being sufficient to account for the
 non-execution of the  absorbent faculty,
 and consequently,  for  the collection of
 the water.  But although part of this
 mixed tumour is undoubtedly owing to a
 fluid, and such fluid as is lodged within
 the vaginal coat, yet it is a very different
 disease  from the. true simple hydrocele,
 and ought not  to be confounded with it;
 one of these marks of the latter being the
 natural, soft, healthy state of the testicle;
 and  the characteristic  of the  former,
 being its diseased and indurated enlarge«
 ment."
   Mr. Pott does not mean that, in a true
 simple hydrocele, the testicle is never al-
 tered from the natural state.  He knows
 the contrary, and that it is often enlarged
 in size, and relaxed in structure, and that
 the spermatic vessels are frequently vari-
 cose. But, the testicle is never indurated.
 These two diseases are extremely unlike
 each  other,  and require very different.
 treatment.   That  which  would cure a
 simple  hydrocele  would  dangerously ag.-
 gravate the hydro-sarcocele.
   Mr. Pott observes, that " it may, and
 does  sometimes become necessary  to  let
 out the  water from the vaginal coat of a
 testicle,  in some  degree diseased; hut
 this should always be  done with caution,
 and under a guarded prognostic; lest the
 patient  be not only disappointed,  by not
 having  that permanent  relief, which,  for
 want of better infoi niation, he may be in-
 duced to expect; but  be  also (possibly)
 subjected to other unexpected inconve-
 niences  from the attempt.
   " When the  disease  is a perfect, true,
 simple hydrocele, the testicle, though fre-
quently somewhat enlarged, and perhaps
 loosened in its vascular texture, is nevei-
 theless sound, healthy, and capable of exe-
 cuting  its proper  office; neither  is the
 spermatic cord, any way  altered from ■<■.
 natural state, except that its  vessels are
 generally somewhat dilated;  neither of
 which circumstances are objections either 
10*4
HYDROCELE.
to the palliative or radical cure of the
disease.  But  in those disorders, which
in some degree resemble this, the case is
different; either tlie testicle, or sperma-
tic cord,  or both, bearing evident marks
of a diseased state.

METHODS OF CURING THE HYDROCELE OF THE
            VAGINA! COAT.

  " The  methods of cure  (says  Pott)
though various, are reducible to  two,
(viz.) the palliative, or that which  pre-
tends only to relieve the disease in pre-
sent,  by  discharging the  fluid; and the
radical, or that  which aims at a perfect
cure, without leaving a  possibility of re-
lapse.  The end of the former is accom-
plished by merely  opening  the contain-
ing bag in such manner  as to let out the
water •• that of the latter cannot be ob-
tained, unless the cavity of that bag be
abolished, and no receptacle for a future
accumulation  left.  One  may be  prac-
tised at all times of the patient's life, and
in almost any state  of health and habit:
the other lies under some restraints and
prohibitions;  arising from  the circum-
stances of age, constitution,  state of the
parts, &c.
  " The  operation by which the fluid  is
let out, is  a very simple one.  The only
circumstances requiring our attention in
it,  are,  the  instrument  wherewith  we
would perform it; and the place  or part
of the tumour,  into which  such instru-
ment should he passed.
  " The two instruments in  use,  are the
common bleeding-lancet, and the trocar.
  " The former having  the finer point,
may possibly  pass  in rather the easier,
(though  tlie difference  is hardly percep-
tible)  but  is liable  to   inconveniences,
to which the latter  is not. The trocar, by
means of its cannuli, secures the exit of
the  whole fluid without a possibility  of
prevention ;   the  lancet cannot.   And
therefore it frequently happens when this
instrument is used, either, that some of the
water is  left behind; or that some degree
of handling and squeezing is required for
its expulsion; or,  that  the  introduction
of a probe, or a director, or some such in-
strument, becomes necessary for the same
purpose.   The  former  of these  may in
some habits be productive of inflamma-
tion :  the latter  prolongs  what  would
otherwise be a short operation, and mul-
tiplies the necessary instruments ;  which,
in every operation  in surgery, is wrong.
 To which  it may be added,  that if  any of
the  fluid be left in the vaginal  coat, or
 insinuates itself into the cells of tlie scro-
 tum, the patient will have reason to think
 the operation imperfect,  and to fear that
he shall not  reap even tlie temporary aft*
vantage which  he expected.' The place
where this puncture ought to be made,  h
a circumstance of much more real  const*
quence;  the success of the  attempt, the
ease, and even sometimes the safety of the
patient, depending upon  it.
  " All the anterior  and lateral parts  of
the vaginal  coat are  loose and detached
from the albuginea; in its posterior and
superior part, those two tunics make onei
consequently the testicle is, as  it were,
affixed to the posterior and superior  part
of the cavity of the sac of an hydrocele;
and consequently, the water or  fluid can
never get quite round it.   This being the
state of the  case, the operation ought al-
ways to be performed on that part of the
tumour, where the two coats are at the
greatest distance from  each other, and
where the fluid must therefore  be accu-
mulated in  the largest quantity;  anil
never on that  part of  it  where the fluid
cannot possibly be.   The consequence  of
acting otherwise, must not  only produce
a  disappointment, by not  reaching the
said fluid; but may prove, and has proved,
highly  and  even fatally mischievous  to
the patient.
  " After performing this operation,  pre-
sent practitioners content themselves with
a  bit of lint, and a  plaster; and  if the
scrotum has been considerably distended,
they suspend it in a bag truss; and give
the patient no farther trouble.
   " In most people,  (continues Pott) the
orifice  thus  made heals in a few hour",,
(like that made for blood-letting;)  but in
some  habits and  circumstances,  it in-
flames and  festers;  this festering is ge-
nerally superficial only, and is soon quiet-
ed by any simple  dressing; but it some-
times is so considerable, and extends so
deep, as to affect the vaginal coat, and by
accident produce a  radical cure.  Mr.
Pott  has also .seen  it  prove still more
troublesome,  and even  fatal:  but  then
the circumstances both ofthe patient, and
ofthe case, have been particular.
   " Wiseman and others have advised de-
ferring the  puncture, till a pint of  Huid
has collected.   When there is a sufficient
quantity, however,  to keep the testicle
 from the instrument, there  can be no rea-
 son for deferring the  discharge; and the
 single  point  on  which this  argument
 ought  to rest, is this:  Whether the ab-
 sorbent vessels, by which the extrava-
 sation  should  be  prevented,  are  more
 likely to reassume their office, while the
 vaginal coat  is thin, and has  suffered
 but little violence  from distention;  or
 after it has  been stretched  and distended
 to ten or perhaps twenty times its natu-
 ral  capacity;  and by such distention is- 
HYDROCELE.
105
(like all other membranes) become thick,
hard, and tough ?  Mr. Pott  thinks the
probability so much more on the side of
the former, that he should never hesitate
a moment about letting out the water, as
soon as he found,  that the puncture could
be  made securely.  And  from what has
happened within  the  small  circle of  his
own experience, he is inclined to believe,
that if it  was performed more early than
it generally is, it might sometimes prevent
the return of the disease."
  The palliative  cure shoidd in general
be performed at least once on those, who
determine to undergo a radical one, as it
gives an opportunity of  examining the
state ofthe testis, and also of permitting
the cavity to be filled again only to  such
a size, as may be thought to be best cal-
culated  to insure success in  any future
operation.  (~Sir James Earle on the Hydro-
cele, p. 13, edit. 2.J
  Upon the  subject of  performing the
operation  of tapping  hydroceles,  Pro-
fessor Scarpa gives us some usefid cau-
tions. The analogy, which exists between
large scrotal herniae and hydroceles of
considerable size, led this writer to sus-
pect, that, in the latter disease, the dis-
placement and  separation of the vessels
of the spermatic  cord from  each other
might  also  happen.  Careful  investiga-
tions, made upon  the dead subject, fully
justified the conjecture.   In  all consider-
able hydroceles, he found the spermatic
vessels so displaced and  separated, that
the artery and  vas deferens were ordina-
rily situated on  one side  of the tumour,
and the veins on  the other.   Sometimes
these vessels all extended over the lateral
parts of the tumour, as far as its anterior
surface, principally towards the bottom.
  It is well known, that, in many instances,
the operation of punctoring a  hydrocele
has, been followed by a large extravasa-
tion of blood within the tunica vaginalis ;
but, Scarpa informs us, that until lately,
he was unacquainted with any case of this
kind, which  was  well detailed  and au-
thentic enough, to be cited as an example
of injury of  the spermatic artery in the
puncture of a  hydrocele.  This learned
Professor, however, has had such a fact
recently communicated to him by liaspa-
rnli, a distinguished surgeon of Pallaiiza,
who, in  introducing the trocar into the
lower part of the swelling, had the mis-
fortune  to injure the  spermatic artery,
and the patient  was afterwards castrated.
The wound of this vessel was most clear-
ly proved by the  part iculars of the case,
as detailed in Scarpa's work,  to which  I
must refer the reader.
  " From the accurate knowledge,  (says
Scarpa) which  we now have  upon  this
     Vol. II.
pathological pohit,  such an accident may
be avoided, by observing the rules, which
are elsewhere given for opening the sac
of a  very  large scrotal hernia. In this
last  operation, as well  as that "of punc-
turing an old and voluminous hydrocele,
care must  be taken to  introduce the in-
strument at a considerable  distance from
the bottom of the tumour,  that is to say,
a little below its middle part, and on a
line, which would  divide the swelling
longitudinally into  two perfectly   tqual
parts.  Experience  proves, that,  for the
purpose of completely  emptying an hy-
drocele, it is  unnecessary to make the
puncture very near  the bottom of the tu-
mour. The corrugation of the scrotum,
and a slight pressure, made by the sur-
geon's hand, will suffice for discharging
all the fluid  contained  in  the tunica va-
ginalis, even when the puncture is  made
at the middle part of the swelling.  (Scar-
pa,  Traite des Hernies, p. 64—68.)

    RADICAL CURE Or THE HYDROCELE.

  Six  different  operations  have  beem
practised  for this purpose; viz. the in-
cision, the excision,  the application of
caustic, the introduction of a tent, the
employment  of  a  seton,  and injecting
some stimulating fluid into the cavity of
the tunica vaginalis.
  The principle,  on which the  success of
every plan of this  kind depends, is the
excitement of such a degree of inflamma-
tion in the tunica  vaginalis, and  tunica
albuginea,  forming  the cavity which con-
tains the water,  as shall end  in a mutual
and  general  concretion  of those  mem-
branes with each other, by which, it  is
evident, the  receptacle  for a  future ac-
cumulation of fluid is completely obli-
terated.
  All the above  plans are not equally eli-
gible  Some of them, indeed, are now
quite exploded: some, which are still
practised by a few,  are not more success-
ful, though certainly more severe, than
one, which will be presently recommend.
ed; others are  very  uncertain  in their
effect, as well as painful.

                Incision.

  Making an incision,  so as to lay open
the cavity containing the fluid, is the most
ancient method,  being described by Cel-
sus.  Paulus -Tigineta says, the incision
is to  commence at  the middle of the tu-
mour, and be carried to the upper part of
it, in a line parallel to the raphe.   This
incision is only to go through the integu-
ments , the bag, which contains the wa-
ter,  is then to be opened, and part of the
    O- 
106
HYDROCELE.
 sides of the sac taken away.  A  director
 is next to be introduced,  and a division
 of the tunica vaginalis made to  the bot-
 tom  of the swelling.  The cavity is after-
 wards to be dressed with lint, and healed
 by granulations.   Hildanus,  Dodonaeus,
 Wiseman, C'ucsclden, Ileister, and Sharp,
 all coincide in stating the dangerous and
 even fatal consequences sometimes  fol-
 lowing this mode.  Mr. B. Bell, who pre-
 ferred this operation to  every other one,
 acknowledges that he has seen it produce
 great pain and tension  ofthe abdomen,
 inflammation and  fever.   Pott observes,
 that  it can never be said to be totally void
 of danger, and  that it bears  the appear-
 ance of an  operation of some  severity.
 This eminent surgeon abandoned tlie me-
 thod, during the last twenty-six  years of
 his life.  Severe as it is, it has also been
 known to fail, as Sabatier and Earle have
 confirmed.

                Excision.

   Albucasis  gives the first clear  account
 of this operation, though Celsus  has cer-
 tainly mentioned removing some of the
 sac.  White  and Douglas used to  adopt
 this method.  The latter advises making
 two  incisions,  so as to  form  an oval,
 from the upper to the lower  part of" the
 tumour;  dissecting off'the oval  piece of
 the scrotum, and then making an opening
 into the sac,  and enlarging it with scis-
 sars.   The  tunica  vaginalis was  next  to
 be entirely cut away, close to where it is
 connected with  the spermatic  vessels.
 The  cavity  was afterwards  filled with
 lint.   Sir James  Earle justly  notices,
 that  this plan must  have  been  tedious,
 exquisitely painful in the  performance,
 and,  as subsequently treated, attended
 with  violent and dangerous symptoms.

                Caustic.

   Paulus ^Egineta advises destroying the
 skin with a cautery of a particular form,
 dissecting off the eschar, and then caute-
 rizing the exposed membrane.  Guido de
 Cauliaco  is,  perhaps, the  first who de-
 scribed the application of caustic for the
 cure  of the  hydrocele   Wiseman  .prac-
 tised  this  method.   Dionis  advises  it;
 but, De la Faye and Gareugeot make ob-
jections to it.  Mr. Else has left the best
 account of the manner of using  caustic.
 He recommends laying " a small caustic
 upon  the anterior and inferior part of the
 scrotum, which is intended to affect, and,
 if possible, penetrate through the tunica
 vaginalis."
  The objections to  the employment of
caustic  are, its  causing  an unnecessary
 destruction of parts, and producing a tedi-
 ous painful sore.   The action oicaustic
 can never be so regulated as to make an
 opening with certainty through the tunica
 vaginalis,  so that  either its application
 must sometimes be  repeated, or else a
 lancet, or trocar used  after all.  Its suc-
 cess is also less sure, than that of an  in-
 jection; but it is  preferable to  all the
 other  methods, except this latter, and,
 perhaps, the seton.

                 Tent.

   This is first  mentioned  by  Franco.
 The operation  consists  in  making  an
 opening into the  tunica vaginalis, and
 keeping the wound open with  a tent of
 lint, linen, or sponge,  so as  to make the
 cavity suppurate, in which the water was
 contained.  Pare,  Guillemau,  Covillard,
 Ruysch, Heister, and  Marini, have all de-
 scribed the  plan,  with some variations,
 one of which consisted in smearing the
 tents with irritating substances.   The fa-
 mous Monro devised the plan of keeping
 a cannula in the tunica vaginalis; so as
 to bring  on a cohesiou  of the parts,
 without suppuration.   Fabricius ab Aqua-
 pendente,  however, has made allusion to
 some surgeons before him, who used to
 keep the  wound open a few days with a
 cannula.   Mr. Pott tried the cannula, but
 found it very inconvenient, as its inflexi-
 bility hurt the testis whenever the patient
 moved with inattention, and, consequent-
 ly, he preferred a tent, or bougie, though
 he speaks of the plan as a very uncertain
 one.
   Of late, M. Larrey,  in consequence of
 having  seen  several  instances,  in which
 the symptoms,  follgwing the use of an in-
jection, were violent, and one  case,  in
 which  a  fatal  peritonitis was produced
 by this mode  of treatment, has  recom-
 mended, exciting the necessary degree of
 inflammation by keeping  a short piece of
 an elastic  gum catheter in the puncture,
 which instrument also  serves afterwards
 to let any  fluid escape from the tunica
 vaginalis.   (Mem. de Chirurgie Militaire,
 Tom. 3,p. 409, &c.) This author, of course,
 speaks of  the plan as having fully answer-
 ed his expectations; but, 1 much doubt,
 whether it has  any  particular superiority
over several of the former  methods  of
employing the tent; methods, which the
wisdom, arising  from  past  experience,
has long since rejected.

                 Seton

Is first mentioned by Cuido de Cauliaco,
1363, as a  means of curing the hydrocele.
In  modem times,  Pott preferred it to 
HYDROCELE.
107
 every other method, if we except injection,
 of which, according to Sir J. Earle, he
 expressed his  approbation before his de-
 cease.   Mr. Pott  found,  that the  best
 mode of making the seton was, as follows.
 He employed three instruments: the first
 was a trocar, the cannula of which was
 about one-fourth of an inch broad.   The
 second  was what  he called  the  seton-
 cannula, which was made of silver, was
 just  small  enough to  pass with easa
 through  the cannula of the trocar, and
 five inches  long.   The third instrument
 was, a probe 6 1-2 inches long, having at
 one end a fine  steel trocar point, and, at
 the other,  an  eye,  which  carried  the
 seton.  The seton  consisted of so  much
 white sewing-silk,   as  would  just pass
 easily through the cannula, and vet fill it.
 The  thickness  of  the  seton, "however,
 was not so great in the latter part of his
 practice.  Having  pierced  the  inferior
 and anterior part of the tumour with the
 trocar, withdrawn the perforator,  and dis-
 charged the water,  Mr Pott used to pass
 the seton-cannula  through' that  of  the
 trocar, to the upper part of the tunica
 vaginalis, so as to be  felt  there.   The
 probe, armed with  the seton, was  next
 conveyed through the latter cannula, and
 its point  pushed through the upper  part
 ofthe tunica vaginalis and scrotum.   The
 silk was then drawn through the  cannula
 until a sufficient quantity was brought out
 of the upper orifice.  The  two cannula
 being1 withdrawn,  the  operation   was
 finished.

                Injection.

   Dr.  Monro attributes the  first use of
 injections for the radical cure of hydro-
 celes to an army-surgeon of his own name,
 who first used spirits of wine.  This pro-
 duced a cure, but,  the inflammation was
 so  violent, that he afterwards  tried a
 milder injection, which consisted of wine.
 However, M. Lambert, above a century
 ago, in his GSuvres Chirurgicales, publish-
 ed at Marseilles, advised injecting a solu-
 tion of sublimate and lime-water, and he
 has related cases of success.   Mr. Sharp
 also made trial of spirit of  wine, which
 cured the hydrocele, but, not without caus-
 ing dangerous symptoms, and two subse-
 quent abscesses in the scrotum. ( Opera-
 tions of  Surgery.J   Douglas, Le  Dran,
 and Pott,  all disapprove of injections, in
 their  works; though Sir James Earle in-
 forms us, that the latter lived to alter his
opinion on the subject
  The violenee of the inflammatory symp-
toms, consequent to the first employment
of injections for the radical cure  of hy-
droceles, arose from the fluids used being
  too irritating.  Sir James Earle, at last,
  preferred wine for several reasons.   He
  found, that it had been used with suc-
  cess in France;  its strength is never so
  great as  to render it unsafe: and it may
  be readily  weakened.  This injection, in
  short, produces  less pain, than any other
  mode  of  eure, does nothing more  than
  is intended, and  is as  certain  as  any
  plan.
   " I have  commonly used  (says Sir
  James Earle) about two-thirds of wine to
  one-third of water; if the parts appeared
  insensible,  and no pain  at all was pro-
  duced by  the first quantity  thrown in, I
  have withdrawn  the syringe, and added
  to the proportion  of wine,- on the  con-
  trary,  if the complaint was  recent, and
  the parts irritable, I have increased the
  proportion  of  water, so that I have hi-
  therto been principally  guided by the de-
  gree of sensation,  which the patient has
  expressed.   I have lately used pure water
  mixed with wine, and found it answer as
 well  as when astringents were added."
 (P. 103. Treatise on the Hydrocele, Edit. 2 J
 In the preface, the author says, that he
 has long disused the pipe with  a stop-
 cock,  which he  once  employed, on  ac-
 count of  not being well able to  spare a
 hand,  during the  operation, to turn  it,
 and its consequently  being  found awk-
 ward.   A pipe, one end of which is made
 to fit into the cannula of a trocar, the
 other  adapted  to receive the neck of an
 elastic bottle,  with • a  valve, or ball,  in
 the centre of the pipe  to permit the en-
 trance, and prevent the exit, of the  in-
 jection, will be  found infinitely more
 convenient and useful,   f Earle. J   When
 the hydrocele is very large, Sir James re-
 commends simply- letting out the fluid, and
 waiting, till the tumour acquires a more
 moderate  size,  before attempting the rar
 dieal cure by injection.
   It appears  from  Sir James  Earle's in-
 teresting cases, that a cure may be accom-
 plished in this manner, even  when  the
 tunica  vaginalis  is considerably thick-
 ened.   The  following  is  the common
 mode  of operating: the hydrocele is to
 be tapped  with a  trocar at its anterior
 and inferior part, and, when the whole of
 the fluid is evacuated, the cavity  of the
 tunica  vaginalis is to be distended to its
former dimensions  with  the above  injec-
tion.   This is to be allowed to remain in
the part about five minutes,  upon  the
average, after which it is to be discharged
through the cannula.  The patient  usu-
ally feels  some pain  in the  groin, and
about the kidneys, on the injection being
introduced; which  symptoms  are rather
desirable,  as they evince, that the  sti-
 mulus  of the fluid is likely to have the 
108
HID
HYD
      wished for effect of exciting the necessary
      degree of inflammation.  This plan, now
      brought to so high a pitch of perfection
      by Sir James Earle, may be deemed al-
      most  an  infallible means of obtaining a
      permanent cure; and being the  mildest
      method,  also, is, of course, universally
      preferred.
        The treatment after the operation  is
      exactly like that of the common  swelled
      testicle (see Hernia Humoralis J, consisting
      ofthe use of fomentations, poultices, saline
      purges,  and,  above all,  of a bag truss for
      keeping up the scrotum.
        There  is a particular case,  that has
      been  called the congenital hydrocele, by
      which is implied a collection of water in
      the tunica vaginalis, in consequence  of
      there being a preternatural communica-
      tion  between  it and the cavity  of the
      peritonaeum.  Desault used to  cure this
      disease by a  red-wine  injection.    Any
      protruded viscera being returned into the
      belly, and the opening between that and
      the inside of the tunica vaginalis being
      carefully compressed and closed  by  a
      trusty assistant, this celebrated surgeon,
      after letting out the water in tlie common
      way, used to  throw in the injection.  The
      method is said to succeed,  without caus-
      ing a perilous  circumstance, one might
      d priori expect, viz. inflammation of tlie
      peritonaeiun. (See Desault par Bichat. J
        This kind of by drocele,  has  not been
      described by most writers.  The  case  is
      easy of discrimination from the fluid be-
      ing capable  of being pushed  into the
      belly.  The French state,  that this  dis-
      ease admits of a cure by injections,  first
      taking care to press the upper part of the
      cord,  so  as  to keep the  injection from
      coming into contact into the peritunxum.
      A successful  instance of this practice is
      related,  by which a  boy was cured both
      of a congenital hydrocele and  hernia.
      The patient was nine years old, and had
      in his  scrotum,  ever  since he was born,
      a fluctuating  semi-transparent tumour,
      which was free from pain,  of  the  size  of
      a large egg, and disappeared, when com-
      pressed, and  in  a  horizontal posture.—
      (See (Euvres Chir. de Desault, Tom. 2,  p.
      4-42.)
        The success of the vinous injection  in
      hydroceles of the tunica vaginalis, in en-
      crysted ones  of the chord, and in other
      cases, in which Sir James Earle has tried
      it,  particularly in a large ganglion, and a
      collection of the patella, makes  it  pro-
      bable, that it will  be found extensively
      useful in  all cavities, where we wish to
      procure an adhesion,  without destruction
      of parts. (Ei.rle.p  158, ,-at. 2. J
«*■•      One caut'.u it is nece.ss.uy to offer, be-
     fore taking our  leave of this  .subject;  it
 has sometimes happened, during the ope-
 ration,  that the  cannula has slipped out
 of the  tunica  vaginalis,  and  its  inner
 mouth  become situated in  the substance*
 of the scrotum, in which event, the ope-
 rator, if he persists in  propelling in the
 injection, will fill the cellular  texture of
 the part with a stimulating fluid, which
 may cause sloughing,  and  other unplea-
 sant symptoms, without entering the ca-
 vity of tlie tunica vaginalis, or affording
 the least prospect of a radical cure of the
 hydrocele.  When such an accident hap-
 pens, it is best to defer the operation, till
 a sufficient quantity of fluid lias collected
 again.  Hydroceles  have been cured by
 applying to the scrotum a solution of sal
 ammoniac in vinegar and water.  ("Aeate.J
 But, the application frequently creates a
 good deal of pain and irritation, and does
 not ofteu succeed, to say the   best of it
 CEarte.J
   For information, relative to  the hydro-
 cele, the reader is  particularly referred
 to Monro on the Tumours ofthe Scrotum, in
 tlie Edinb. Med. Essuys, Vol. 5..  Pott on
 the  Hydrocele;  El*;e  on tlie  Hydrocele;
 Keate ;  B. Bell; Douglas ;  and Sir James
 Earle on (he same.  Memoire sur VHydrocele
par Bcrtrundi, in Mem. d» VAcad. de Chi-
 rurgie,  Torn. 3.   Also  the  same author in
 Trattato  delle  Operazioni  di   Cliirurgta.
 Nizza,  1763.   Remarques,  &c. sur diver-
 ses especes d'Hydrocele, en QZuvres Chirur-
gicales  de  Desault, Tom.  2.    Sharpe's
 Treatise on the Operations,  and his Critical
 Enquiry.  Also Sabatier  in Medecine  Ope-.
 ratoire,  Tom.  1.  Scarpa, Traite des Her-
 nies, p.  64, &c.  Lurrey, in Memoires de
 Chirurgie Militure,  Tom. 3, p. 409, Ire.
 Practical Observations on tlie Sclerocele, &c.
 by T. Ramsden, surgeon to  thrift's  Hos-
pital, £jc.
  The mode  of distinguishing a hydro-
 cele from a scrotal  hernia, as  explained
 by  Pott, is described in the article  Her-
 nia.
  HYDROPHOBIA, (from  o$up, wuter,
 and <Po$eu,  to fear )  A dread of water.
 This being a  striking symptom  of  that
 species  of madness, which results  from
 the  bite of a  mad dog, and some other
 animals  affected  in the same wav, the
 disease  itself has  been named  Hydro-
phobia.  Some have used the more general
 term, hygrophobia, from  oy^ot,  liquid.
  Both  these terms  are highly   objection-
 able, because they  are  derived  from a
 symptom,  which  'does  not exclusively
 belong to the  disease,  nor constantly ex-
 ist in it.
  The old writers, as we learn from Cx-
 Uus Aurelianus, used the  terms aerophobia,
o; a dread ./ air, ard pantophobia, or, a 
HYDROPHOBIA.
169
fear of all things, as appropriate names for
the disease, since  the impression of cold
air sometimes excited terror, and the dis-
order is  marked by a singular degree of
general  timidity  and  distrust.   Others
called it phobodipson (oir»9t  signifying
thirst,) because the patient is thirsty, yet
J'ears to drink.  Several modern  authors,
however, objecting to an appellation ex-
pressive only of one symptom, hai'e more
correctly denominated-the disease  rabies,
and rabies  canina,  or  canine madness,
The French call it la rage.  (Reesl Cy-
clopxdia, art. Hydrophobia.J  Aristotle is
the  first writer, that  expressly mentions
this disorder; but, he appears  to have
had a very  imperfect idea of it,-since he
 sets down man as exempt from the danger
 of being affected by it.
   Animals of the dog kind,  including the
 wolf and the fox, are most frequently the
 subjects of rabies; and some writers have
 maintained, that,  although it may be re-
 ceived and propagated by other  animals,
 yet it always originates with some of the
 canine race.  (Hillary on Diseases of Bar-
 badoes,  p. 246 )  Wrong notions, of a very
 dangerous tendency, have been generally
 entertained,  in regard to the  disease,
 as it appears  in  the canine  race.   The
 writer  of  the article Dog, in Dr Rees'
 Cyclopaedia, appears to  have  had most
 extensive  opportunities of  observing the
 disorder in dogs,  having paid attention
 to more than two hundred  cases.  From
 his remarks,  I have collected the follow-
 ing information.
   The  peculiar symptom,  which charac-
 terises the complaint in  the human  sub-
 ject, has been applied to the disease  in
 the dog, and has  occasioned it to be call-
 ed by the same name, hydrophobia.   This
 is a p.dp.ible misnomer;  for, in  no in-
 stance, does  there ever exist  any dread
 of  water;  on the contrary, dogs are in
 general very greedy after  it.  Such un-
 founded supposition has  often conduced
 to a very fatal error; for, it being the re-
 ceived  opinion, that  no dog is mad,  who
 can lap water,  many persons  have  been
 lulled  into a dangerous security.  An-
 other equally false  and fatal idea  has
 prevailed, that every  mad dog must of
 course be   wild and furious ; but,  this is
 so far from being true,  that, in the great-
 er number  of instances, there is very  little
 of  that wild savage fury, that,  is ex-
 pected  by tlie  generality of  persons.
 "Hence,"  says this author,  "as  it  is
 evident, that the term hydrophobia, cha-
 racterising the affection in the dog, is a
 misnomer, so it is evident, that the term
 madness is equally  so.  In no  instance,
 bave 1 ever observed a total alienation of
 the mind; in very few,  have the  mental
faculties been  disturbed.  The disposi-
tion to do mischief is rather an increased
irritability, than  absence of sense; for,
in most instances, even those  that are
furious, they acknowledge  the master's
voice, and are obedient."  The symptom,
which is most frequently first observable
in a rabid dog,  is a certain peculiarity in
his manner;  some  strange  departure
from his usual  habits.  In a very  great
number of instances,  the peculiarity con-
sists in a disposition  to pick up straws,
bits of paper, rag, threads,  or tlie small-
est objects, which may happen to be on
the floor  This is said to be particularly
common in  small dogs.   " Others again
shew an early peculiarity by licking the
parts of another dog.  In one instance,
the approach of the disease was foretold,
by  our  observing  a  very uncommon at-
tachment in  a  pug puppy,  towards  a
kitten,  which he was  constantly licking;
and  likewise the cold nose of a healthy
pug, that was with him.   An attachment
to the  sensation of cold appears in many
cases,  it being  very  common to  observe
them (the dogs) licking the  cold iron,
cold stones, &c.  Some dogs, early in the
disease, will eat  their own excrement,
and  lap their own  urine."  An early an-
tipathy to strange dogs  and cats  is very
commonly  observed,  but, particularly to
cats.   As the disease  advances, the affect-
ed dogs bite those with which they are
domesticated,  and,  lastly,  the  persons
around; but, except  in a moment of irri*
tability they seldom attack the human
subject. The  irritability,  that  induces
them to bite is  very  strong; but, is  de-
void of wildness.   It  is more like peevish-
ness, than fury.  A stick held up at them
always  excites their  anger in a  violent
degree, and, throughout the disease, there
is generally a  wonderful impatience  of
controul, and the animals are  with great
difficulty frightened. (See  art. Dog in
Rees' Cyclopxdiu J
   For  additional details, relating to the
disease as it appears  in  the dog,  I must
refer to the  paper, which has  been just
now quoted.  Enough, I hope, has been
said to make the reader  aware, that mad
dogs are not particularly characterised
by an  inability  to lap water, or  any de-
gree of  fury.  These animals, when ac-
tually  affected with  rabies,  from their
quiet manner, have even not been suspect.
ed of having the disorder, and have even
been allowed to  run  about, fondled, and
even slept with.   (See Mem.  of Swedish
 Acad.  1777.)
   The causes of this peculiar distemper
 in dogs are at present in much obscurity,
 and we  have little more, than conjecture
 upon the subject.  We  do not positively" 
110                            HYDROPHOBIA.
 know, whether  rabies sometimes origi-
 nates spontaneously in these animals, or,
 whether,  like small pox, in  the / human
 species, it is propagated only by conta-
 gion.  That  th% disease is frequently im-
 parted in consequence of one dog biting
 another,  every body  well knows.   But,
 still, there are many instances, in  which
 it is certain, that no such cause can be
 suspected  Several facts  tend to shew,
 that among dogs the disease is often com-
 municated by contagion.   It is observed,
 that, in insular  situations, dogs are sel-
 dom  affected, and this circumstance  is
 ascribed to such animals being in a kind
 of quarantine.   The celebrated sports-
 man, Mr.  Meynell, secured his dogs from
 the maLdy, by making every new hound
 perform a quarantine before he was suf-
 fered to join the pack.  (See Trans, of a
 Society for the Improvement of Med.  and
 Cldr. Knowledge,  Vol  1, art. 17.)  Great
 heat is very commonly  supposed to be an
 exciting  cause of the  disease in  dogs;
 but, without much foundation.  •' A very
 hot  climate,  or  one exposed to the ex-
 tremes of heat and cold; a very hot and
 dry  season;  feeding upon putrid, stink-
 ing  and maggotty flesh; want of water;
 worms in the kidneys, intestines,  brain,
 or cavities of the nose," are set down by
 Boerhaave as causes  of  the  disease.—
 CAphorism, 1134.)  We learn  from Dr.
 J. Hunter,  that in the hot island of Ja-
 maica, where degs are exceedingly nu-
 merous, not  one  was  known  to go mad
 during forty years.  (Transactions of a
 Society for the Improvement of Medical
 Knowledge, loc cit.)
  "  Although (say s M. Larrey) hydropho-
 bia is more frequent in warm, than tem-
 perate climates, it is  not observed in
 Egypt, and the natives assured  us,  that
 they knew of no instance,  in  which  this
 disease had manifested itself either in
 man, or   animals.   No  doubt, this is
 owing to  the  species and character of the
 dogs of this  country,  and  their manner
 of living.
  " It is  remarked, that the  Egyptian
 dogs are almost continually in a state of
 inaction: during the day,  they lie down
 in the shade, near vessels, full of fresh
 water, prepared by  the  natives.  They
 only run about in  the  night time;  they
 evince the signs and effects of their love
 but once  a year, and only for a few in-
stants. They are  seldom seen coupled.
 On  our arrival, there Was  a vast number
 of these animals in Egypt, because, they
 were held, like many others, in great ve-
 neration,  and  were never put  to death.
 They do  not  go into the houses: in the
 day time,  they remain at the sides of the
 streets, and they only wander into  the
 country  at night, in order  to find  any
 dead animals,  which happen  to  be  un-
 buried.  Their disposition is  meek  and
 peaceable, and  they rarely fight with each
 other.  Possibly,  all  these  causes may-
 exempt them from rabies."  (Larrey, in
 Mem. de Chir. Militaire, Tom. 2, p. 226.)
   In  Mr.  Meynell's  account, which  was
 communicated  to him by a physician, it
 is asserted,  that the  complaint  never
 arises from hot weather, nor putrid pro-
 visions, nor  from any cause except  the
 bite; for, however dogs have  been c»u-
 fined, however fed,  or, whatever may
 have  been the heat of the season, the  dis-
 order never commenced, without a possi-
 bility of tracing it to the preceding cause,
 nor was it ever introduced  into the ken-
 nel,  except by the bite of a  mail dog.
 This  malady is also  stated to be rare in
 the northern parts of Turkey,  more rare
 in the southern provinces of that empire,
 and totally unknown under  the burning
 sky of Egypt.  At  Aleppo,  where these
 animals perish in great numbers, for want
 of food and water, and  the  heat  of  the
 climate, this disorder was never known.
 In other  parts  of Africa, and in the hot-
 test zone of America, dogs are said to be
 never attacked  with madness.  (See  art.
 Dog,  in Rees' Cyclopxdia.)
  Mr. Gillntan endeavours to prove, that
 the disease in dogs  is probably produced
 independently of particular climates, of
 putrid aliment, of deficiency of water, of
 want  of  perspiration, or, of the worm
 under the tongue, to which it has been at
 different times ascribed, and he expresses
 his belief, that it originates somewhat like
 typhus in the human  subject, and is  not
 always  produced  by   inoculation  by
 means of a bite.  He thinks,  that  it may
 be occasionally brought on  by  the con-
finement  of dogs,  without exercise,   in
close  and  filthy kennels; and that  the
success of Mr.  Trevalyan, as related by
Dr. Bardsley, in clearing his kennel  of
the disease,  by changing even the pave-
ment,'after other means of  purification
had failed, affords presumptive  evidence
in favour  of the  opinion;  and,  conse-
quently, this author thinks,  that the me-
thod of quarantine, adopted by Mr. Mey-
nell, and recommended by Dr. Bardsley,
on the supposition, that  the disease ori-
ginates exch'sively from contagion, will
not be a sufficient preventive alone; and
he shews, from some facts, reported by
 Mr. Daniel, that  the poison  sometimes
 lies dormant in dogs four, five, and  six
 months;  and,  consequently, he  infers,
 that  the period of two months is not a
 sufficient quarantine, before a new  dog is
 introduced into a pack.  (See Gillman'a
 Diss,  on the Bite of a Rabid Animal. J 
HYDROPHOBIA.                            Ill
  It is observed by the late Dr. J. Hunter,
that all domestic animals, birds, as well as
beasts, are susceptible of the poison of
the mad dog; and,  indeed, our expe-
rience has not yet taught us that there is
any race of animals exempted from its ef-
fects.   Whether every animal labouring
under the disease is capable of infecting
others, or whether this power is  confined
to a few only, we are yet to learn
  The disease has been communicated to
the human species by dogs,  cats, wolves,
and foxes.   The  dog, the wolf", and the
jackal, have, by the late mquiries of na-
turalists, (Mr. Hunter's paper, Phil. Trans.
Vol. 77, p- 253.) been ascertained to be of
the same species; and therefore it is pro-
bable, from analogy, that the latter is ca-
pable of communicating the infection as
well as the two  former.  The fox also
has a strong affinity to the dog, and is by
Linnaeus counted of the same genus ; but
the distinctions of natural  history will
not avail us  here; for the cat, an animal
of a very different genus, has often pro-
duced the hydrophobia in the human spe-
cies.  Many other animals  are  reported
to have the power of infecting others, by
biting them while labouring under the
disease themselves; but the facts hitherto
collected are very vague, and lead to no-
thing conclusive on this head.  Were we
to judge from analogy,  from seeing two
animals so  different from each other as
the dog and the cat, capable of infecting
others,  we  might be led to infer, that
every animal susceptible of the disease
had the power of communicating it, pro-
vided their natural habits led them to bite
and tear with their teeth such animals as
came in their  way while in an enraged
state.  But, though  there  are instances
of  men labouring under hydrophobia bit-
ing some of those employed in taking
care  «f them,  no ill consequences have
been known to follow.   .From this,  how-
ever, we can draw  no positive  inference,
for it is but a  small proportion of such
persons as  are bit by dogs undoubtedly
mad, who are infected with the poison.
   The bite  only  serving the purpose of
inoculation, the danger arising  from  it
will he various, as it happens to be in a
part  more  or less  vascular; or as the
teeth are more or less  loaded with the
poison.   There  is the  greatest danger
from  bites in the face, and  the symptoms
come on soonest;  bites  in the hands also,
which are generally bare, are full of dan-
ger.  In other parts of the  human body
the clothing, by wiping the teeth, greatly
lessens the danger of infection.   The bite
is not essentially- necessary for the appli-
cation of the poison :  a dog, by  licking a
sore, produced the hydrophobia; but he
licked it till it bled, so thaV the poison
came in contact with the newly divided
blood-vessels.  This circumstance, if we
may judge from the analogy of other poi-
sons, is probably  of importance in giving
efficacy to the poison, yet it is  not  clear
that it is essential j for there are two cases
of the  disease mentioned in the Philoso-
phical Transactions, (Phil. Trans. Vol. 23,
p. 1074.) which arose from putting the
hands in the mouth of a puppy that was
mad, but  when there was  no bite; and
there is a similar case in the Memoirs of
the Royal Academy of Sciences of Swe-
den.  (Anno 1777.)  It  is  true,  various
other modes  of infection are narrated by
writers, but in all of them there is much
appearance of fabulous credulity.   There
is good reason to think that tetanus has
sometimes been mistaken for hydropho-
bia, and given rise to the accounts of the
diseases  proceeding from  the  bite of a
cock,  the claw of a cat, and similar hist-
tories.
   Dogs are much more susceptible of the
infection than the  human species.  Four
men  and  twelve  dogs  were bit by the
same mad dog, and every one of the dogs
died ofthe disease, while all the four men
escaped, though they used no other means
of prevention, but such as we  see every
day to fail.  There is also  an instance of
twenty persons Ibeing bit by  the same
mad dog, of whom only one had the dis=-
ease.
   There  is  a question  which »aturally
presents itself here; does the disease ever
arise spontaneously in  the human spe-^
cies ? The facts relating to this question
involve many doubts.  Francis  Stannier
died in November 1787, with the symp-
toms of hydrophobia, though it was not
known that he had ever  been bitten by  a
mad dog; (London Med. Journal, Vol. 9.
p. 256.) and  similar cases are related by
writers.  Yet as  a large  bite is no way
necessary to  communicate the  infection,
the patient  above-mentioned  may have
been slightly bit,  without knowing it, as
he was often drunk, and frequently .in the
streets at night.  There is good reason to
believe that  the difficulty of swallowing,
which sometimes  occurs in tetanus, has
been mistaken for hydrophobia in soro?
cases ; and  there may  be other spasms
about the throat  and   the oesophagus,
which may so far resemble hydrophobia,
as to give rise to errors on this subject.
Something of this kind occurred once to
Dr. John Hunter, in  an hysteric woman.
 Were we to  be guided by analogy in de-
ciding the present question, we should be
led to deny  the existence of spontaneous
hydrophobia; for where  is  there  an ex-
 ample of ar.v  of those diseases  which  de-t 
112                           HYDROPHOBIA
 pend npon a specific poison, as the small-
 pox,  the venereal disease, or the measles,
 arising spontaneously ?  But the full deci-
 sion of this question must be left to future
 experience and observation.  (Dr. J. Hun-
 ter in Trans, of a Society for the Improve-
 ment of Med. and Chirurgical Knowledge,
 Vol. l,p.  299—303.)
   Dr Heysham has defined hydrophobia
 to be an  aversion and horror at  liquids,
 exciting a painfitl convulsion of the pha-
 rynx, and occurring at an  intermediate
 period  after the canine virus has been re-
 ceived into the system.  Dr. Cullen places
 it in the class neuroses, and order spasmi,
 and defines it a loathing and great dread
 of drinking any liquids,  from their creat-
 ing a painful  convulsion of  the pharynx,
 occasioned most commonly by the bite of
 a mad animal.   Others have suggested the
 following  definition., as  more  complete:
 melancholy, dread of cold air; of any thing
 shining, and particularly of  water; often
 arising  from the bite of  a mad  animal.
 (Parr's Med.  Diet. J However, the latter
 definition  is, perhaps, equally objection-
 able,  because  there  is  not invariably a
 dread 0/ shining bodies.  (See Dr. Powell's
 Case, p. B.J
   Writers in general have divided hydro-
 phobia into two stages, viz. the melancholy,
 and the raving;  the hydrophobia simplex,
 and rabiosa, of Cullen. In many instances,
 however,  the latter stages of the disorder
 are not preceded by any condition, to
 which the epithet melancholy is applica-
 ble.
   With regard to the symptoms of hydro-
 phobia, they are generally tardy in  making
 their appearance, a  considerable, but a
 very variable space of time usually elaps-
 ing between their commencement and the
 receipt of the bite.  This interval in the
 greater number of instances appears to
 be  about  six weeks.  Out of a  table of
 131 cases, none ofthe patients became ill
 before the eleventh day after the bite, and
 only three  before the  eighteenth.  Dr.
 Hamilton  thinks  nineteen  months  the
 longest interval, to which any credit can
 be given. (On Hydrophobia, Vol. 1. p. 113.)
 On the other hand, Dr. Bardsley, of Man-
 chester, has recorded a case, in which the
 most  careful enquiries  tended to prove,
 that the^ patient  had never  suffered the
 least  injury from any animal, except the
 bite, inflicted twelve years previous to the
 commencement ofthe hydrophobia, by a
 dog apparently mad.  (Mem. of Liter, and
 Phil. Society of Manchester, Vol 4,  Part 2,
p. 431.)  The  wound, if treated by com-
 mon methods,  usually heals  up at first in
 a favourable manner.' At some indefinite
 period,  and, occasionally,  long after  the
 S;tte;i part seems quite well, a slight pain
begins to  be felt in it,  now and then at-
tended with itching, but generally resent-
bling a rheumatic pain  It soon extends
from the wound  up the arm,  and affects
the situation of the trepezius muscle, and
the  neck,  on the same side as the bite.
The cicatrix, in tlie  mean while, begins
to  swell,  inflames, and, at length, dis-
charges an  ichorous matter.   There are
often pains of a  more flying,  convulsive
kind, felt in various  parts  of the  body.
As the disease advances, the patient com-
plains of the pain shooting, from the si-
tuation of the bite, towards the region of
the heart.  A lassitude, a dull pain in the
head, and a vertigo, soon  come on : the
patient is commonly  melancholy, though
not  always,  mutters,  is  forgetful, and
drowsy ; his mind seems disordered; his
temper irritable and irregular; his slum-
bers disturbed, and convulsive agitations
immediately follow his waking: a  deaf-
ness is sometimes complained of; the eyes
are watery; the aspect sorrowful; the
face pale and contracted ;  sweat  breaks
out upon the temples;  and an  unusual
discharge of saliva is made from the mouth.
From the beginning, a peculiar stricture
and heaviness  on the  breast, occasional
involuntary  sighing,  and  nausea,  take
place.  There is often a bilious vomiting.
The idea of drinking any kind of  fluids
creates considerable  alarm and agitation,
and the attempt to do so generally brings
on most  afflicting pains and convulsions,
attended with a dreadful sense of suffoca-
tion, and choaking.  Dr. Marcet, in re-
lating the case of a patient affected with
hydrophobia, observes, that " on our pro-
posing to him to drink, he started up, and
recovered his breath by a deep convulsive
inspiration : yet, he expressed much re-
gret,  that he could not drink,  as he con-
ceived, it would  give  him  great  relief,
his mouth being  extremely parched and
clammy.  On being  urged to try,  how-
eyer,  he took up a cup of water  in one
hand, and a tea-spoon in the other.  The
thought of drinking out of the cup ap-
peared to him intolerable; but, he seemed
determined to drink with the spoon. With
an expression of terror, yet,  with  great
resolution,  he filled the spoon, and pro-
ceeded to carry it to his lips;  but, before
it reached his mouth, his courage forsook
him,  and he was forced to desist. He re-
peatedly renewed the attempt; but, with
no more success.   His arm became  rigid
and immoveable, whenever he tried to raise
it towards his mouth, and  he  struggled
in  vain against  this spasmodic resistance.
At last, shutting his eves, and, with  a
kind  of convulsive effort, he suddenly
threw into his mouth  a few drops of the
fluid, which he actually swallowed.  But, 
HYDROPHOBIA.                           US
at the same instant, he jumped up from
his chair, and flew to the end ofthe room
panting tor breath, and in a state of inde-
scribable terror."   (See Medico-Chirurgi-
cal  Transactions, Vol. 1, p.  138.)  Even
the  splashing, or running, of any liquid
causes  a great deal of inconvenience.  As
the  system  becomes more  and more af-
fected, the patient loses his sleep entirely,
and has frequent and violent fi.sot" anxiety
and loud  screaming from slight causes.
The woman, whom Dr.  Powell attended,
was often attacked in this  way, in conse-
  auence of so trivial a circumstance as a
  y  settling on  her  face.  The noise of
tea-cups, or the mention  of any sort of
drink greatly disturbed her, though  she
was not at all agitated by the sound of
her urine. The currents  of air entering
her room, whenever the door opened, be-
came very distressing to  her, and this
more and more so.  The pain in her neck
became so great, that she could  scarcely
bear it to be touched; but she made  use
of  a looking-glass  without  the inconve-
nience which hydrophobic patients usually
suffer from the sight of shining bodies.
Dr.  Powell states,  that the paroxysms
which  this poor woman suffered, resem-
bled those of hysteria, and increased in
duration as the disorder  lasted.  "She
described their commencement  to be in
the stomach,  with a working and fulness
there,  and that a pricking substance pass-
ed  up  into her throat and  choaked  her;
she screamed  suddenly,   and  grasped
firmly  hold of her attendants, as  if volun-
tarily; and muscular convulsions  came
on, which were  sometimes  more, some-
times  less general and  violent.   The
causes from which these paroxysms arose,
were extremely slight; the passage of a
 fly near her  face, the attempt to swallow
a pill,  a stream of air, the sight of oil or
 wine,  or any  other liquids,  even  the
sound  of water, and other  such circum-
 stances,  were  sufficient;  she  now  also
complained of inconvenience from light,
 which was accordingly moderated.  The
 effects of sounds was peculiar; for, though
 in the  subsequent  stages,  their influence
 became more general, at this period the
effect  was  rather  proportionate to  the
 ideas they excited  in her mind, than  to
 their  violence.  Bells, and other strong
 noises, did not agitate her, but the clatter
 of  earthen ware,  the  noise of a distant
 pump, or any  thing connected with  li-
 quids, produced the paroxysms in all their
 violence."  She could swallow fresh cur-
 rants  with less resistance than any  thing
 else, taking care that they were perfectly
 dry.   Her mind had, till now, been quite
 calm and composed, and her conversation
     vox. n.
and  behaviour proper, during the inter-
vals of the convulsive  attacks.   Bui Dr.
Powell was  ooliged  to discontinue  the
pills of  argentum  nitratum,  in conse-
quence ofthe sufferings which the attempt
to swallow them regularly  brought on.
Fifteen grains  of this substance had been
given without any sensible  effect.  The
fits and irritability  to  external objects,
increased.  The pain shot from the back
of the neck, round to the angles of the
jaws, the chin,  and  throat.   At  length,
the paroxysms  became  more  frequent,
and, indeed, might be said  to  come  on
spontaneously:  seven  occurred  in  one
hour.  She  looked  pale  and exhausted,
and a tremor and blueness of her lips and
fingers  were  observable; her pulse be.
came weaker and  more  rapid,  and her
scalp so tender,  that touching it brought
on convulsions.  She had, latterly,  eruc
tations of wind, and spit up some  thick
viscid saliva.  Her urine  now came away
involuntarily, and she was more and more
irritable  and  uncontrollable.   She now
passed two hours in almost constant con-
vulsions ;  became extremely irritable and
impatient of every thing about her,  com-
plained of failure of her sight; wished
to be bled to death; her words were fewer
and  interrupted; she struck, and threat-
ened to bite, her attendants; had copious
eructations of air; discharged an increas-
ed  quantity of viscid saliva with much
convulsive effort; said the  affection of
her  throat  and stomach  had quite left
her; and continued in  a  general perspir*
ation,  with a weak pulse from 140 to 150.
She  afterwards  bit  some of the  attend-
ants, and was therefore confined with a
waistcoat.  From  this period,  she had
lost all control over her  mind,  and con-
tinued  for  almost  four  hours in a  pa-
roxysm of  furious  insanity.   She  now
swallowed, with an effort, near half a pint
of water: but this was, in a few seconds,
vomited  up, with some  mucus, and  a
greenish  fluid.   In  this violent raving
state,  she continued till within  two hours
of her death, which took place forty-seven
hours after the first marked occurrence of
hydrophobia.  , In the course of  the case,
she swallowed, once or twice, a little por-
ter ; and also  some cinnamon-water, with
tinct opii; but they were always vomited
up.  On opening the body,  tiie most re-
 markable appearances were,  a  turgid
 state of the vessels  of tlie  hrain ;  great
 distentions of the iutestines  with air; the
 oesophagus rather  redder  than natural,
 and covered with a thin layer of coagulat-
 ing lymph ; nearly halt a pint of greenish
 fluid in the stomach,  which was rather
 redder than  natural, and had under its
     P 
114                            HYDROPHOBIA.
      internal coat,  new the cardia, a few spots
«     of extravasated blood.  (Dr. Powell's Case
      of Hydrophobia.)
         The dread  of  swallowing  liquids,
      though the most singular symptom of the
      disease, constitutes but a small part of the
      malady.  It is true, that  none, or very
      few recover, who have this  symptom, yet,
      tiiey certainly do not die, in consequence
      of the  difficulty of swallowing liquids;
      for, the human  body  could  easily exist
      double the time, in which the disease usu-
      ally proves fatal, without food, or drink.
      Besides, the sick can often swallow sub-
      stances, that are  nourishing, in a pulpy
      s|Ute, without, however, having their life
      ttiereby at all prolonged. It is not, there-
      fore, the  difficulty,  or impossibility of
      swallowing liquids ; but the effects ofthe
     poison  upon  the constitution  at  large,
      which occasions death.  (Dr J. Hunter iu.
      Trans, of a Society for the Improvement of
     Med. Knowledge, Vol. 1, p.305.)
       The extreme sensibility of tlie sick to
     all  impressions, appears in the displea-
     sure which they  express at even the air
     blowing upon them ;  iu their dislike to a
     strong light;  in their aversion to new
     feces,  or even  the  sight of their  friends
     and relations ;  and in the terror they ex-
     press  at being  touched, which  almost
     threatens to throw them into convulsions.
     As the disease advances, the mind is more
     and more filled with  dreadful  fears and
     apprehensions. (Dp. ci:. p. 307.)
       The duration o* life,  from the appear-
     ance of the hydrophobia till  death, varies
     from thirty-six hours to tour or five days :
     the most common  period is from two to
     three days. (Op. cit. p.  308.)
       The dread of water is said to  be some-
     times a symptom of certain fevers, from
     topical inflammations  of the  thorax, or
     neighbouring  parts. (Edinburgh Medical
     Commentaries.  Vol  2, p. 331.)  A species
     Of hydrophobia has been knows  to origi-
     nate from an inflammation  of  the  sto-
     mach.   (Med. Essays, Vol 1.)  Also from
     the bite of an epileptic patient, or of per-
     sons in viblent fits of passion; and from
     the accession of epilepsy.  An inferior de-
     gree of it is said to be observable in some
     hysteric cases,  when,  from the difficulty
     of swallowing, patients are fearful of tak-
     ing liquids. In the latter cases, musk and
    opium are recommended.
      With respect to the  treatment of hy-
    drophobia, arising from the canine  poi-
    son, little is necessary .to be said in  this
    work, because the subject is rather medi-
    cal than  surgical.   The reader will re-
    gret my brevity the less, when he is in-
    formed, that, after hydrophobia has once
    begun,  it has always pursued its dreadful
    course  to a fatal  termination,  without
 anyone well authenticated instance to tit*
 contrary,  notwithstanding  the  trial  of
 every medicine, and  method,  which the
 a!4est practitioners have suggested.  The
 only case, that I have ever periled, which
 seemed really to be one, in which hy dro-
 phobia  was  cured, was published  iji a
 Calcutta paper, of December, 1811.  The
 treatment, if my memory  fails me  r.n',
 consisted  in  mercurial frictions, and co-
 pious and repeated bleedings.   The par-
 ticulars, I believe, however, are likely to
 be made public in one of the  periodical
 works, long  before  this  edition of the
 dictionary will  be completed.  If this
 were a true case of hydrophobia,  it is ex-
 traordinary, that a  method, which has
 been often and often  tried in  other in-
 stances, should have  answered  in  this
 particular one.   The  same observation,
 in regard to the inefficacy, of every mode
 of treatment hitherto known, might,  per-
 haps, be accurately extended to every in-
 ternal remedy, mercurial frictions, plung-
 ing the patient for a considerable time
 under water, &c. as preventives.  The in-
 stances, in which a prevention  has  been
 inferred to have taken place by  different
 writers, in consequence of such means,
 may all be<( very rationally ascribed to
 other circumstances   It is well  known,
 that, out ofthe great number of persons,
 f. equently bitten by the same  dog, only a
 few are commonly affected.  The hydro-
 phobic poison is known to reside in the
 saliva of the animal; consequently,  the
 chance of being affected must greatly de-
 pend upon the quantity of this fluid, which
 may be insinuated into the wound; and,
 if the teeth of  the animal should have
 previously pierced a thick  boot, or other
 clothing, before entering  the  skin,  the
 danger must obviously be in general much
 diminished.   Many patients  Wash  and
 suck the wound, immediately after its oc-
 currence, and thus, no doubt, very often
 {?et  rid of  the poison.  Even when it lias
 odgedin  the wound, it  may not be di-
 rectly absorbed, but be thrown off with
 the discharge   All prudent patients sub-
 mit  to excision of the  bitten part.  Now,
 under each of the  above  circumstances,
 escapes have frequentlv occurred, while
 internal  medicines, half drowning, or sa-
 livating  the patients,  h id also  not been
 neglected,  so that all the efficacy of pre-
 ventives has too often been most unjustly
 ascribed to means, which probably never
 yet had, nor ever will have, any beneficial
 effect whatever.  What confirms the truth
 ofthe preceding  statement are these feels;
 that persons  bitten by  the  same animal
have  sometimes been treated exactly on
the same plan;  some  of them  have es-
caped having  the disease; others have 
                  HYD

had it, and, of course, perished:  on other
occasions, some of the patients, bitten by
the same animal, have  been treated in a
particular way, and  have escaped hydro-
phobia,  while others bitten at the same
time by  the animal, also never had any
constitutional effects, altliough they took
no medicines, nor followed any other par-
ticular plan.
  Happily,  there is,  in  surgery,  one
means of preventing hydrophobia, when
it is practised in time,  and in a complete
manner.   Every reader will know,  that
the excision ofthe bitten parts is the ope-
ration to which I allude.  Indeed, as hy-
drophobia is often several months before
it begins,  the wounded parts should, per-
haps, always be  cut out,   even though
they are healed,  and some  weeks have
elapsed  since the accident,  provided no
incipient  symptoms of hydrophobia have
already   commenced.   The   operation
should be done completely; for a timor-
ous surgeon, who should tear-to cut deeply
enough,  or to cut a  sufficient quantity of
the surrounding  flesh  away, would be a
most dangerous one  for the patient.  All
hopes of life depend on tlie  prevention of
the disorder : for, in the present state of
medical  knowledge, none can rest upon
the efficacy of any plan, except the extir-
pation of the part. This some have done
with caustics.  However, as  their action
can never be regulated with the same pre-
cision as  that of die knife,  and, conse-
quently, they will not always destroy the
flesh to a sufficient depth, excision should
always be preferred.   The latter method
is also the safest, for another important
reason,  viz. the part, and poison lodged
in it,  are removed from the body at once;
but,  when caustic  is  used, tlie  slough
will not be thrown off for some  days af-
terwards.
  Some surgeons of  the present  day are
not  content  with cutting  out the part;
they  recommend,  after  the operation,
filling the wound with the  aqua  ammo-
nix  purs, so as to produce a  general
sloughing ofthe surface, by way of greater
security.
  I shall conclude this article with  re-
ferring the reader to  the following works,
for  farther information on  hydrophobia:
Sauvages sur la Rage ; James on Canine
Madness; Mead on the Bite of a J fad-dog;
Seleg, Augent, and Hamilton, on Hydropho-
bia; Medical Museum,  Vol. 2; London Me-
dical  Transactions, Vol 2; Med. Obs and
Inq. Vol.3;  Edinb.Med Comment. Vol. 5,
p. 42/ Vaughan's  Two  Cases of'" Hydropho-
bia ; Dr. PowelTs Case of Hydrophobia;
Lotto's  System of Surgery, Vol.3; Cullen'b
First Lilies,  Vol 4,-  Memoirs of the Med.
Society of London, Vol. I, p. 243/  Medical
               HYD              115

Communications, Vol. 1; Mem. ofthe Royal
Society of Medicine in Paris, Supplement to
Vol. 4. Ferriar's Med. Facts and Observa-
tions.Richerand'sJVbsographie Chirurgicale,
Tom.  1, p. 251, &c.  Edit. 2. Marcet,  in
Medico-Chirurgical  Transactions,   Vol.  1,
p. 132, &c. Lassus,Pathologie Chirurgicale,
Tom.  2, p. 239, SJc. Edit.  1809.  A valua-
ble paper by Dr. John Hunter in Trans, of a
Society for the Improvement of Me d.and Chi-
rurgical Knowledge,  Vol. 1, Art. 17.  Gill-
man's Dissertation on the Bite of a Rabid An-
imal.  Leveilie, JVouvelle Doctrine Chirurgi-
cale, Tom 2,p- 341, &c.   Bardsley in Sle-
moirs  of the Literary and Philosopldcal So-
ciety  of Mancfiester, Vol. 4,  Part  2.  Ba-
bington, in the Medical Records and Re-
searches, liond. 1T98.
  HYDROPHTHALM1A.   (from  u^t
water;  and oty6xXp.oct the eye.)   Dropsy
of tlie eye.  In all the cavities of  the ani-
mal body, (says Scarpa)  which  are conti-
nually moistened by a serous vapour,  as
well as in those destined to  contain a de-
terminate quantity of an  aqueous, limpid
fluid, there is such a reciprocalness of ac-
tion,  between the secerning extremities
ofthe arteries, and the minute mouths of
the absorbent vessels, that the fluid effused
in these  cavities is always in circulation,
being incessantly renovated,  but  never
accumulating beyond a certain degree and
determinate measure. When this mutual
action, existing between these two vascu-
lar systems, is interrupted, in consequence
of a  general or local indisposition, the
above cavities, being no longer moistened
by a  serous vapour, shrivel and  become
obliterated;  or, on  the  contrary,  being
unusually  distended by the  excessive
quantity of fluid, they acquire an enor-
mous  magnitude, much  beyond  what a
person,  unacquainted with  these things,
would suppose
  As  Scarpa continues, the eye, considered
simply as a cavity destined to contain a
certain quantity cif limpid fluid,  is occa-
sionally subject to both these infirmities.
The first is  termed atrophy ; the sec md,
dropsy of the eye, or hydrophthalmia.  In
the first case, the globe of the  eye gra-
dually becomes smaller;  and, as  the ab-
sorbent  system  does not cease acting,
when there  is no  more  fluid to be ab-
sorbed,  it gradually consumes the solid
parts  of this organ, which  it insensibly
diminishes, and in time destroys.  In the
second  case, the eye assumes a greater
bulk  than is  natural  to it; sometimes ac-
quiring such an e vtraordinary magnitude,
that it propcts out of the eyelids, at first
with great weakness, and afterwards with
total  loss of  sight.
  Surgeons generally state, that  the im-
mediate causs ofthe dropsy ofthe eye, is 
116                         H YDROPHTHALMIA
 sometimes an increase of tlie vitrous hu-
 mour, sometimes ofthe aqueous.  In every
 case of this kind, on which Scarpa has
 performed the operation, and in other ex-
 aminations of the different  stages of the
 disease, made on the dead subject, he has
 constantly  found the vitreous humour,
 more or less, altered in its organization,
 liquified,  and  converted into  water, ac-
 cording as the  disease  was ancient,  or
 recent.  In some  instances, he could not
 distinguish whether the increased quan-
 tity ofthe vitreous or the aqueous humour
 had most share in  the formation of the
 disease.  Some  of  the  most  celebrated
 modern oculists  believe, that  the princi-
 pal cause of this complaint is referrible
. to  the closure of the  inorganic pores of
 the cornea, through which the  aqueous
 humour can no longer transude, and con-
 sequently collects in the interior of the
 eye, so as  to occasion dropsy.  By this
 assertion, they evince, that they are not
 sufficiently  acquainted with the activity
 ofthe  absorbent system in the animal eco-
 nomy ; and they do  not seem to have ad-
 verted that,  in  conformity  with their
 theory, the dropsy of the eye ought inva-
 riably  to follow  a thickening of the con-
junctiva spread  over the organ, as well
 as  the leucoma and extensive scars  of
 the whole cornea; a thing that is  con-
 tradicted  by  daily  observation and  ex-
 perience.
   Scarpa  has also dissected a dropsical
 eye, taken from the body of a child, three
 years and a half old, who died  of maras-
 mus.  The vitreous  humour was not only
 wanting in  this  eye, and the cavity des-
 tined  for its  reception filled with water;
 but the  vitreous tunic  was  converted
 into  a substance,  partly of  a  spongy,
 partly of a  lippomatous nature.  This
 dropsical  eye  was one-third larger  than
 the sound one.   The sclerotica was not
 thinner than that of the other  eyej but,
 in consequence of being yielding^flaccid,
 and separated from the choroides, it had
 lost its plumpness, and globular shape.
 The cornea formed a  disk,  one-third
 larger than that of this membrane in a
 sound  state ; it  did  not retain  its natural
 pulpousness, and was obviously thinner
 than the cornea of the healthy eye. There
 was a  considerable quantity of an aque-
 ous, reddish  fluid,  between the  cornea
 and iris.  The crystalline  lens, with its
 opaque capsule, had been pushed forward
 a little way into the anterior chamber,
 but could not  advance  further on  ac-
 count  of a firm adhesion, which the cap-
 sule had contracted with the iris, around
 the edge  of the pupil.  As soon as the
 capsule was opened, the lens issued from
 it, half dissolved, the rest exceedingly
soft.  It was  impossible  to detach  the
whole of the posteriour layer of the cap-
sule from a hard substance, which seemed
to be the altered membrane ofthe vitreous
humour.  Scarpa, therefore, slit open the
choroides, from the ciliary  ligament to
the bottom of the eye,  when a consider-
able  quantity of a reddish aqueous fluid
gushed out,  without, however, one parti-
cle of the vitreous humour.  In lieu of the
latter body, there was found a  small cy-
linder of a substance, partly of a fungous,
partly of a lippomatus nature,  surround-
ed with a good deal of water, which was
effused in the longitudinal  axis of  the
eye, from the entrance of the optic nerve,
as  far as  the  ciliary  ligament, or  that
hard substance  to which the posteriour
layer of the capsule firmly adhered.  This
little cylinder was covered, for the extent
of two lines and a half forwards from the
entrance of the optic nerve,  by a stratum
of whitish matter, reflected on itself, like
the  epiploon, when raised towards  the
fundus of the  stomach.  Scarpa conceiv-
ed that this stratum  of  whitish matter
was  nothing else than the relics of  the
unorganized retina; for, on pouring rec-
tified spirits of  wine on the whole  inner
surface of the choroides, and.the  little
cylindrical body, he found no vestiges  of
the  retina on this membrane, and Ihat
the whitish substance, which was reflected
on itself, became very firm, just as  the
retina does when  immersed in spirit of
wine.  Both the cylinder and the  indu-
rated substance, occupying the place of
the ciliary body, were  manifestly nothing
else  than the  membrane  of the vitreous
humour destitute of water, and converted,
as was described, into a substance, partly
of a  spongy, partly of a lippomatous  na-
ture. It is not easy to  determine whe-
ther this fungous and  lippomatous dege-
neration  of the  vitreous  tunic had pre-
ceded, or was a consequence ofthe dropsy
of the eye. _ However,  it may  be,  this
fact,  in conjunction with  several other
similar  ones, that Scarpa has met  with,
in which he found no vitreous humour in
the posteriour cavity ofthe eye, but only
water, or  a bloody lymph, tends  very
much to confirm that this disease princi-
pally consists of a  morbific secretion  of
the  vitreous humour,, and  occasionally,
also,  of a strange degeneration of the al-
yeolary  membrane, bv which this humour
is formed   Scarpa refers to a  similar
case  in Medical  Obs. and Inquiries, Vol. 3,
Art.  14.
  The augmentation  in the  secretion of
the aqueous fluid, both in the cells ofthe
vitreous  humour and  out of them, after
they have been  ruptured from  excessive
distention; together with a debilitated 
HYDROPHTHALMIA.                         117
    action of the absorbent system of the eye
    affected; are, most probably, continues
    Scarpa,  the  causes  of every species of
    dropsy, and, consequently, of the morbific
    accumulation  of  humours  in  the  eye.
    From such  a lodgment and successive
    increase of the vitreous and aqueous hu-
    mours,  the  eye-ball  at first necessarily
    assumes an oval shape, ending at the point
  -  of the cornea; then, as  the organ en-
    larges in all  dimensions,  it acquires a
    larger size  than  that of  its fellow; so
    that, in the end, it projects from the orbit
    in such a manner, that it cannot  be co-
    vered by the eyelids, and disfigures the
    patient's face as much as  if an ox's eye
    were placed  in the orbit, instead of his
    own natural one.
      This disease (says Scarpa) is sometimes
•   preceded by blows on the  eye, or adjoin-
    ing  temple;  sometimes by an  obstinate
    internal ophthalmy.   In other instanc-s,
    it is preceded by no other inconvenience
    except an uneasy sensation of tumefaction
    and distention in the orbit, a difficulty
    of moving the eye-ball, and a considerable
    impairment of sight.  Lastly, it is some-
    times preceded by  none of these causes,
    or  no other obvious one whatever, espe-
    cially when the complaint occurs in  chil-
    dren, of very tender age, from whom no
    information can be obtained.  As soon as
    the eye has assumed an oval form, and
    the anteriour chamber has become pre-
    ternaturally capacious, the iris seems si-
    tuated further backward than usual, and
    tremulates, in a very singular way, on the
    slightest motion of the eye-ball.  The pu-
    pil  remains  dilated  in every degree  of
    light,  while the crystalline is sometimes
    brcvnish from the very beginning of the
    disease; and sometimes it does not be-
    come cloudy till the  affection has arrived
    at its highest pitch.  The complaint tliea
     becomes stationary;  and, as the crystal-
     line is not deeply opaque, the patient can
     distinguish light from darkness, and,  in
     some degree, the contour of objects, and
     brilliant colours.  But, when the eye has
     acquired a larger volume, and the whole
     crystalline has become opaque, the retina
     at last remains  in  a state of  paralysis,
     from the excessive distention, and, conse-
     quently,  is no  longer sensible to  such
     few rays of light as  reach the bottom of
     the eye, by insinuating themselves at the
     sides of the lens.
       In the  last stage of the disease,  (con-
     tinues the above celebrated surgeon) when
     the dropsical eye projects from the orbit,
     so as not to  admit of being covered by
     t he eyelids, with the  inconveniences al-
     ready enumerated, others associate them-
     selves, arising from  the friction  of  the
     cilia:, the secretion  of gum, the flux of
tears, the ulceration of the lower eyelid-,
on which the eye  rests, and the excoria-
tion  of the eye itself.  Hence, the drop-
sical eye is gradually attacked by violent
ophthalmies,  attended with  intolerable
pains ofthe part affected, and of the whole
head.  The ulceration, also does not al-
ways confine  itself within certain limits;
but  continues  to spread,  first depriving
the cornea of  its  transparency, next con-
suming the sclerotica, and lastly, destroy-
ing  progressively the other component
parts of the eye-ball.
   At the first appearance of the dropsy
of the eye,  the masters of the art recom-
mend the internal administration of  mer-
curials, the extract of cicuta, and of Pul-
satilla nigricans; and   the external em-
ployment of astringent and  corroborant
collyria, making a  seton  in  the nape of
the neck, and compressing the eye, which
forms a  preternatural  projection out of
the  orbit.  As far, however, as Scarpa
can judge, from the events of observations
made  by the  best  practitioners on this
point, he has never yet met with a single
well-detailed  history of a dropsy of the
eve  cured by means  of  the above-men-
tioned  internal medicines.  With regard
to externals, he has learnt, from his own
experience, that, when the disorder is
manifest, astringent, and corroborant col-
lyria, as  well  as compression on the pro-
tuberant eye, are highly prejudicial.  In
such circumstances, making a seton in the
nape of the neck, frequently  bathing the
eye in a lotion of mallows, and  applying
to it a plaster composed ofthe same plant,
have enabled  him to  calm, for a time,
that disagreeable sense of distention in
the orbit, and over the  forehead,   and
temple ofthe same side, of which patients
in this state make so much complaint,
especially when they are  affected with a
 recurrence  of ophthalmy. But, as  soon
 as the eye-ball begins to protrude  from
 the orbit, and project beyond the eyelids,
 there is  no means of opposing the very
 grievous dangers, which the dropsy ofthe
 eye threatens, except  an operation", which
 consists in evacuating, by an incision, the
 superabundant humours from  the  eye,
 then exciting gentle inflammation of the
 membrane, and  suppuration on the inte-
 riour of this organ, so as to  make it con-
 tract, and shrink into the bottom of the
 orbit.  To defer the operation any longer,
 would be abandoning the patient to the
 constant inconvenience  of  an habitual
 ophthalmy, the danger of an ulceration
 of the eye-ball and subjacent eyelid, and,
 what is worse, of carcinoma of the whole
 eye, with great peril to tha patient.
   Scarpa next states, that, in  order to
 fulfil the preceding indication, of evacu- 
113
HYDR0PHTHALM1A.
 ating the superabundance of aqueous hu-
 mours lodged in the eye, the paracentesis
 of the ey e-ball has been greatly extolled
 iii past times —Nuck, one of the promo-
 ters of this operation, punctured the eye
 with a trocar, exactly in the centre of the
 cornea.  (De Duct. OcuL Aquos, p.  120.)
 It has since been thought better to punc-
 ture the eye-ball  in the sclerotica,  at
 about two lines from the junction of this
 membrane  with the cornea,  that such a
 small quantity of the vitreous humour
 may be more easily discharged  at the
 same time with the aqueous, as may  be
 deemed adequate to effect a  diminution
 in the  morbific enlargement  of the eye-
 ball.
   Notwithstanding the approbation, says
 Scarpa, which the most celebrated sur-
 geons have conferred on this method of
 operating  for  the dropsy  of the eye, it
 has at present fallen into disuse, as in-
 sufficient, and ineffectual for the purpose.
 This will not appear surprising to  such
 as are acquainted with our present know-
 ledge of the  animal economy, particu-
 larly in regard to the lymphatics, and are
 not ignorant how  little reliance can be
 put in paracentesis, as a means of curing
 chronic dropsy in general, especially that
 of the tunica vaginalis, termed hydrocele.
 Indeed, the radical cure of the latter is
 never accomplished, except when the ad-
 hesive inflammation  takes  place  in the
 tunica  vaginalis and  albuginea, after the
 evacuation  of the  fluid, or  when  these
 membranes suppurate, ulcerate, or con-
 tract an intimate adhesion together, which
 remove every  opportunity, every possi-
 bility of a fresh accumulation of water in
 the scrotum.  If it has sometimes  hap-
 pened, that  the puncture has  radically
 cured the hydrocele, it is because it has,
 by some unexpected incident,  excited in-
 flammation of the vaginalis and albuginea,
'so as to produce a coalescence of these
 two membranes.
   In consequence of these principles, (con-
 tinues Scarpa) the paracentesis of the eye,
 directed wholly for the discharge of the
 superfluity of humours in this  organ, can
 never be a means of curing the dropsy of
 the part, unless the puncture, made by the
 trocar, excite, at  the  same time, inflam-
 mation and suppuration, and afterwards
 a concretion of the membranes composing
 the  eye-ball.  Indeed Nuck relates,  that
 in a young man at Breda, on  whom he
 had operated, he was obliged to puncture
 the  eye five several times ; that, on the
 fifth time of doing this, it was necessary
 to suck through the  cannula of the tro-
 car, in order to evacuate the greatest pos-
 sible quantity  of the vitreous  humour;
 and, lastly, that it seemed proper to intro-
 duce a plate of lead, between the eyelids
 and eye-ball, for the purpose of making a
 continual pressure on the eye, in its empty,
 shrivelled  state.   In  a  woman of  the
 Hague, he mentionstthat he twice punc-
 tured the eye in vain; and that this per-
 son submitted,  two or three other times,
 to the same operation, but he omits  add-
 ing with what degree of success.  Scarpa
 has no  difficulty in believing,  that a ra-
 dical cure of" the dropsy has sometimes
 been accomplished by means of the punc-
 ture,  after the  trocar, and other similar
 hard substances, have been repeatedly in-
 troduced into the eye, through the  can-
 nula of that instrument; but this success
 can never be attributed to the mere eva-
 cuation of  the superabundance of the vi-
 treous and aqueous humour;  tnough it
 may be referred to that,  conjoined with
 the  irritation produced by the cannula,
 and, consequently, to the adhesive inflam-
 mation or suppuration excited in tlie in-
 ternal membrat-.es of the eye.  It is by no
 means unlikely,  that,  after having learnt
 this practical point  from experience, and
 wishing to  insure the success of the para-
 centesis in  the radical cure of the dropsy
 of tiie eye.  Woolhouse may have directed
 that, when the cannula is introduced in
 the eye,  it should be rolled at least  six
 times  between   the  fingers;  and   that
 Platner,  following the  same steps,  may
 have proposed  to  inject  a  warm  fluid
 through the cannula into the cavity of the
 eye,  after having evacuted. the humours,
 by means of a trocar; and that Mauchart
 may have directed keeping open the wound
 made in the eye by the trocar,  by means
 of a small tent of  lint. If all  these cir-
 cumstances prove,  on one side,  the ineffi-
 cacy of  the paracentesis  in the radical
 cure of tlie dropsy of the eye, they  evi-
 dently shew, on the other,  that the perfect
 cure of this infirmity can only be achieved
 by evacuating tiie humours contained in
 the eye; and exciting, at the same time,
 a  certain degree  of  inflammation,  and
 suppuration, of the  internal membranes
 of the organ
  The most easy and expeditious  way
 hitherto known, of obtaining all these ad-
 vantages,  is  undoubtedly  that which is
 explained in tlie  account of the radical
 cure of the  inveterate staphyloma, pro-
 truding out of the eye-lids.  (See Stafthy-
 loma.)   With  respect to this subject,
 Scarpa cannot refrain from repeating, at
 this opportunity,  that it  is exceedingly
disadvantageous, and even dangerous, to
 make the circular section ofthe dropsical
eye-ball in  the  sclerotica.  In  fact,  this
circular recision, when  performed in the
 sclerotica, is constantly followed by the
 most aggravated symptoms, particularly, 
HYDltOPH I" HALMIA.
119
 frequent  hemorrhages, an accumulation
 of grumous blood  at the bottom of  the
 eye-ball,  \ciiement inflammation of  the
 eye, eyehu>, and head, obstinate vomit-
 ings, convulsions, delirium,  and the most
 imminent danger  to  the  patient's  life.
 Such modern surgeons, as have faithfully
 published the results of their practice on
 this point, among whom, Marchan (Jour-
 rial de Med. de Paris. Janvier,  1770.  Sur
 ileux Exophthalmies, on grosseurs contre na-
 ture du  Globe de I'QSU.J and Terras, (Ibi-
 dem; Mars. 1776.  Sur  I'Hydrophthalmie.
 next to Louis,  (Memoires de Chirurg, t.
 13, p.  2»9, 290.)  merit infinite praises,
 have ingenuously declared that, after per-
 forming the circular recision of dropsical
 eyes in  the sclerotica,  they have  had the
 greatest  motives for  repenting of what
 they had done
   The circular section, as broad, or rather
 broader than a  large  lentil-seed, is per-
 formed at the  summit or centre of  the
 cornea  of the dropsical eye,  according to
 Celsus's direction relative to the staphy-
 loma, is exempt from the serious conse-
 quential symptoms  that Scarpa has just
 mentioned.  By means of this operation,
 which is by no means painful, an opening
 is made for the evacuation ofthe humours
 ofthe eye, and internal inflammation  is,
 at  the  sums  time, excited.  These  ob-
 jects are accomplished, also, without oc-
 casioning such a sudden  subsidence,  and
 emptiness, of the membranes of the  whole
 eye, as  necessarily happen when a circular
 incision is made in the  sclerotica,  and
 gi*eatly affect the nerves of this organ,
 and  the parts sympathizing with it, par-
 ticularly  the head  and  stomach.  This
' intimate  sympathy, perhaps, is  not  the
 least of  the causes producing the fatal
 consequences  above   specified;  besides
 those very serious  ones, which necessa-
 rily  result from  the almost sudden expo-
 sure of a large surface  of the deeper part
 of the eye to the contact of the air,  and
 from the  lotions which are,  in these  cir-
 cumstances, often employed.
  With regard to the manual of the ope-
 ration,  it  is exactly the same as what is
 detailed in the article Staphyloma.  In  the
 dropsical  eye,   whether the  cornea  be
 transparent or not,  since the function of
 the immediate organ of sight is irrevoca-
 bly lost, as Scarpa has  already stated,  the
 surgeon must  introduce a small bistoury
 across the apex, or middle ofthe cornea,
 at one  line and a  half from its central
 point; and  then, by pushing the instru-
 ment from one towards the other canthus
 of the eye, he will cut  the lower part of
 tlie crtrnea in a semicircular manner. The
 segment of the cornea being next elevated
 with the forceps, the operator is to turn
 the edge of the knife upward, and com •
 plete the work by a circular removal of as
 much of the centre of the cornea as is
 equal, in size, to a large lentil-seed,  or
 three  lines in diameter, supposing  the
 patient to be in the adult state.  Through
 this circular opening, made in the centre
 ofthe cornea, the surgeon may, by means
 of gentle pressure,  discharge as much of
 the superabundant humours in the eye,
 as is requisite to  make the eye-ball dimi-
 nish, and return into the orbit,  so  as to,
 be covered,with the eyelids.  As for the
 rest of the humour lodged in the eye, it
 will gradually escape of itself, through
 the circular opening in the cornea,  with-
 out any more pressure being made.
   Until the appearance  of the inflamma-
 tion, that  is, until the third  or fifth day
 after the operation,  the dressings are  to
 consist of the application of a pledget of
 dry lint, supported  by a retentive band-
 age.   As soon as the inflammation and
 tumefaction  invade the eye operated on,
 and theeye lids, the surgeon is to employ
 such internal remedies as are calculated
 to moderate the progress of inflammation;
 and he is  to cover the  eyelids with  a
 bread and milk poultice, which must be
 renewed at least once every two hours. It
 is a  very frequent phenomenon, both in
 the staphyloma and dropsy of the eye,
 that, on the first appearance of inflamma-
 tion, the eye-ball o* which the operation
 has been done,  augments, and protrudes
 again  from the eyelids,  in the same way
 as before the operation.   In this circum-
stance, it is proper to cover the projecting
 f»art of the eye-ball with a  piece of fine
 inen,  smeared with a liniment of oil and
 wax, or the  yolk of an  egg,  and  oleum
 hyperici; the application  of  the   bread
 and milk poultice being continued,  as be-
 fore-mentioned, over this other  dressing.
 Scarpa next states, that, when suppuration
 of the  interiour of the  eye manifests it-
 self, the swelling of the eyelids at  the
 same time decreases, and the eye-ball di-
 minishes in size, returns gradually into
 the orbit, and continues to contract itself.
 This state of suppuration may be known
 by observing, that  the dressings  are
 smeared with a viscid  lymph, blended
 with a portion ofthe humours  of the eye,
 which incessantly issue  from  the  centre
 of the cornea; and  by noticing the ap-
 pearance of the  margin  of the recision,
 which is changed into a circle of a whitish
 substance,  resembling the rind of bacon.
 In the progress of the case, this whitish
 circle,surrounding the place ofthe recisiorr
 of the cornea, becomes  detached,  like a
 slough, so as to leave a small  ulcer, of a
 very healthy colour.  This ulcer, as welt
 as the whole eye-ball, contracts, so  as  to 
  120           H Y M

  become  entirely  closed, and cicatrized,
  leaving every opportunity  for the placing
  of an artificial eye between the eyelids and
  the stump of the eye-ball.
    Although, in the majority of cases, the
  circular recision of the centre of the cor-
  nea, equal in size to a large lentil-seed,
  proves sufficient to excite a mild inflam-
  mation, and suppuration, in the interior
  of the eye of  an  adult  subject, yet^ if
  this occurrence does not take  place on
  the fifth day, it is useful  to expose the
  eye, on which the  operation has  been
  done, to the  air;  or, as is stated in the
  article Staphyloma, it is useful to remove
  a  circular portion of the cornea, halt a
  line in breadth, or little more, by means
  of the forceps  and curved scissars.   This
  gives the patient  neither  pain  nor any
  other inconvenience,  and produces the
 desired effect,  viz. it makes the interior
 cf the eye, at length, inflame and suppu-
 rate mildly, without  which it is  impossi-
 ble to effect a perfect cure.  (Scarpa sulle
 Principali Malattie degli Occhi, cap. 13.)
   HY'DROPS.  (from ofy,  water)  A
 dropsy, or morbid accumulation of water.
 For hydrops articuli, refer to Articulation.
 With regard to hydrops pectoris, Ivydrotho-
 rax, or dropsy of the chest, as it is altoge-
 ther a medical case, an  account of its
 symptoms and  treatment will hardly be
 required  in this Dictionary.   The  only
 concern which a surgeon  has with  the
 disease, is being occasionally required to
 make an opening for the discharge of the
 water: this operation is described in Pa-
 racentesis Thoracis.
    HYDROSARCOCELE.   (from cJ^wf,
 water: «•«£|} flesh ; and *j>Aj}, a tumour.)
 A morbid enlargement of the testicle, at-
 tended with a  collection of fluid in  the
 tunica vaginalis.
   HYMEN IMPERFORATE. The incon-
 veniences brought on by such a cause and
 the mode of relief, are explained in the
 article Vagina.
   A  continuation  of the  hymen over a
 part of the orifice of the meatus urinarius
 may produce great pain and difficulty in
 making water, aid symptoms, which  may
 give rise  to  suspicion of there being a
 stone in the bladder.
  The following case  illustrates  this ob-
 servation.   "In  the  year  1740, (says
 Mr. Warner) I was consulted in the  case
 of a httle girl, about three years old,  who
 had long  laboured  under  such severe
 symptoms in voiding her urine, as to make
 it suspected by her physician, that she had
a stone in  her  bladder.  L'pon enquiry,
I was  informed, that her  urine came
away by drops,  that she was  inclined to
put her hand to the pudendum when she
              H Y P

 made water, and that, at that time, she
 could not help crying and stamping  with
 her feet.  These symptoms  so nearly re-
 sembled thofce of the stone, that I thought
 proper to propose the passing a stall uito
 the  bladder that we might be  satisfied,
 whether there was a stone, or any other
 disease  of the urethra, or  bladder;  but,
 upon endeavouring to  do it, I observed,
 that the urethra was at least half covered
 over with a  continuation of the hymen,
 which appeared  imperforated;  for  this
 reason, 1 could with difficulty execute my
 design.   However, I effected  the intro-
 duction  of the instrument into the blad-
 der,  without using much violence;  but,
 there was no stone, nor any other preter-
 natural  appearance to be discovered in
 the  bladder, or  the urethra.  For  this
 reason, I  pronounced, that  the difficul-
 ties and pains, which arose in discharging
 the urine, probably proceeded  from  the
 size  and  situation  of this membrane;
 which I  divided by incision  with a small
 knite," &c.  The  patient was cured in a
 few days.  (See Wanteds Cases in. Surgeiy,
 p. 276, edit. 4.)
   HYPOPYON, or HYPOPIUM.  (from
 u7ro, under;  and zrt/ov, pus.)
   By hypopium (says  Scarpa) I imply,
 with  all surgeons,  that accumulation of a
 glutinous, yellowish fluid, like pus, which
 take place in the anterior ehamber of the
 aqueous  humour,  and, frequently, also in
 the posterior one,  in  consequence of se-
 vere, acute ophthalmy,  particularly  the
 internal  species.    I  have explained, in
 speaking of  inflammation of  the eyes,
 that,  though the severe, acute oplithalmy
 particularly affects the externtd parts of
 the eye, in the majority of instances; yet,
 it  occasionally invades,  with equal vio-
 lenee, both  the external  and  internal
 coats of this  organ, especially  the cho-
 roides and uvea.   In this last  circum-
 stance, if  the inflammatory diathesis, af-
 fecting the interior of the  eye, be  not
 promptly checked  and subdued, by  the
 most  effectual chirurgical means, coagu-
 lating lymph  is extravasated  from  the
 highly inflamed choroides and uvea, and
 gradually,  as it is effused into  the cavity
 of the eye, it passes through the pupil,
 into the chambers ofthe aqueous humour,
 and descends to the bottom  of the ante-
 riour  one, so as  to  fill  sometimes  one
 third, sometimes one half of this space;
 and, occasionally, to occupy it to such a
 height, as totally to conceal the iris and
pupil.
  This viscid matter of the hypopium is
commonly  called pus; but Scarpa con-
tends that it is only coagulating lymph.
The  symptoms portending  an extrava-
sation of coagulating  lymph in the eye, 
HYPOPIUM.
121
r* Sth hypopium, are the same as those
which occur in  the  highest stage of vio-
lent acute ophthalmy:  viz.  prodigious
tumefaction ofthe eye-lids ; the same red-
ness and swelling of the conjunctiva, as
in chemosis; burning heat and pain in
the eye; pains in tlie  eye-brow  and nape
of the neck ; fever,  restlessness, aversion
to the faintest light, and a  contracted
state ofthe pupil.
  As soon as the hypopium  begins to
form, (says Scarpa)  a  yellowish semi-
lunar streak makes its appearance at the
bottom of the anterior chamber, and, re-
gularly, as the glutinous fluid is secreted
from the inflamed internal membranes of
the eye, so as to pass through the  pupil,
and fall  into the aqueous humour, it in-
creases  in  all dimensions, and gradually
obscures the iris, first at its inferior part,
next, where it forms the pupil, and last-
ly, the whole circumference of this mem-
brane.   As long as the inflammatory stage
of the violent ophthalmy lasts, the hypo-
pium never fails to enlarge ; but,  imme-
diately  this stage ceases, and  the oph-
thalmy  enters its second period, or that
dependent  on local weakness, the quan-
tity  of coagulating  lymph, forming the
hypopium,  leaves  off  increasing,  and,
from that moment,  is disposed to dimi-
nish.
  This fact sufficiently evinces (continues
this eminent Professor)  how important it
is,  in order to check the progress  of the
hypopium,  to  employ  with  the  utmost
care, the most effectual means for check-
ing and resolving the attack of  violent
ophthalmy, in  its  first stage.  Copious
evacuations of blood,  both generally  and
topically, ought to  be  speedily put into
practice; and when  chemosis exists, the
conjunctiva should be divided; mild ape-
rients, blisters  to the nape of the neck,
little bags of emollient  herbs, applied to
the eye,  and other measures of this kind,
described on the subject of the first stage
of severe acute ophthalmy, ought to be
employed.  It  will  be  known that they
have fulfilled the indica'tion,  by noticing
that, solne days after the adoption of such
treatment, though there may still he red-
ness, ofthe conjunctiva and eyelids, the
lancinating pains in the eye abate, the
heat considerably diminishes, the fever
subsides, quietude and sleep are restored,
the motion of the eye becomes  free, and,
lastly,  the collection  of viscid  matter
forming the hypopium, becomes station-
ary.  It is not unfiequent to  see, espe-
cially among the lower orders of the peo-
ple, persons affected with the second stage
of severe acute  ophthalmy, bearing this
collection of  coagulating  lymph, in the
chambers  of the aqueous humour, with
    Vol. 11.
the greatest indifference,  and  without
complaining  of any of those  symptoms
which characterize the acute stage of oph-
thalmy.  It is only at this crisis, or at the
termination of the acute stage of violent
inflammation of tlie eye, that the enlarge-
ment ofthe hypopium ceases, and the co-
agulating lymph begins to be, absorbed,
provided this salutary  operation  of na-
ture be not impeded, nor retarded, by any
injudicious regimen.
  Scarpa states, that persons, little vers-
ed in the treatment of diseases of the eyes,
would  fancy  that  the  most expeditious
and efficacious mode of curing an hypo'
piuwi, after  it has become stationary  in
the second stage of severe acute ophthal-
my, would be that of opening the cornea
at its  most depending part, in order  to
procure a speedy exit for the matter col-
lected in the chambers  of the aqueous hu-
mour;  especially, as this is also the com-
mon doctrine.   But experience  shews,
that dividing the cornea, in such circum-
stances, is  seldom  successful, and most
frequently gives rise to evils, worse, than
the hypopium. itself,  notwithstanding the
modification suggested by Richter, (Obs.
C/iir. Fasc. 1, 'Chap. 12.) not to evacuate
the whole of the matter at once,  nor to
promote its discharge by repeated pres-
sure, and injections, but to allow it to flow
slowly  out of  itself.  The wound made
at the lower part of the cornea,  for eva-
cuating the matter of the hypopium, how
small  soever the incision may be, most
commonly reproduces  the severe  acute
ophthalmy,  and occasions a greater effu-
sion of  coagulating lymph in the  cham-
bers of the aqueous humour, than existed
before.  Besides, after  opening the cor-
nea, the matter of  the hypopium,  if al-
lowed to escape gradually, and  in drops,
of its own accord, would be several days
in becoming completely discharged, on
account of  its  viscid  quality.   During
this space of time, the  glutinous lymph
would keep the edges ofthe wound ofthe
cornea dilated, and make them suppurate.
Thus  the  incision  would  be cor.wrted
into an  ulcer, through which the aqueous
humour, situated behind the coagula t inn;
lymph,  would escape,   and r.ew even  a
told of the  iris.  Opening the conea,
therefore, only converts  the  hypopium
into an ulcer of that membrane, attended
with a prolapsus  of the  iris, and i cca-
sionally ofthe crystalline itself.  No:- can
any inference be. drawn in favour of mak-
ing an  artificial opening during  tlie.st.^
tionary  state of an  hypopium in the se-
cond stage of severe acute ophthaiiiiy.f.om
the matter of the hypopium having some-
times made its way spontaneously through
a narrow aperture in the cgmea, with  a 
122
HYPOPIUM.
successful result*  For, there is a wide
difference, between the effects of a spon-
taneous opening into a natural, or pre-
ternatural cavity of the animal body, or
of one made with caustic, and the conse-
quences of an opening, made  with  a cut-
ting instrument.  In  the  two  first  me-
thods,  the subsequent symptoms are con-
stantly milder than in the  last.  Besides,
even in the  instance, in which  a sponta-
neous  exit of the hypopium  takes place
through  the  cornea, an  escape of the
aqueous humour, and a prolapsus of the
iris not unfrequently ensue;  consequent-
ly,  the spontaneous evacuation of the hy-
popium cannot justly form a  rule for the
treatment of the disease.  There is only
one case, in  which dividing  the cornea,
in < • der to discharge an hypopium, is not
only useful, but indispensable: this is,
when there is  such an immense quantity
of coagulating lymph, extravasated in the
eye, that the excessive distention,  which
it produces of all the coats of this organ,
occasions  such  vehement symptoms, as
not only  threaten  the entire destruction
of the eye, but even endanger the life of
the patient.  But,  this  particular case
cannot serve  (says Scarpa) as  a model,
for the treatment of the  hypopium, usu-
ally met with in practice.
  Besides, if it be  certain, that blood ex-
travasated in the eye in consequence of
blows, and what is still more  remarkable,
that even the membranous flakes of the
capsular cataract,  pushed by the needle
from the posterior  into the anterior cham-
ber, are  insensibly  dissolved, and, at
length, entirely absorbed, if it  be the
same with milky, and caseous  cataracts,
that have been iacerated as much as pos-
sible;  and even  with the crystalline  lens
itseltj  when deprived of its capsule, and
depressed into  the  vitreous humour by
the operation; (see Cataract/)  there'ean-
not be a doubt, as  Scarpa states, that ab-
sorption will take  place,  in  the case of
coagulating  lymph extravasated into the
chambers ofthe aqueous humour, as soon
as the source of this extravasation of glu-
tinous  fluid   no longer  exists, and the
lymphatics of the eye have recovered their
original  energy.
  Hence the resolution of the hypopium,
by  means of absorption, forms the pri-
mary  indication, at which  the surgeon
should aim  in the treatment of the com-
plaint.  We have already observed, that,
in  order to  stop  its progress, the only
truly efficacious method is to subdue the
first shock  of the inflammation, and .to
shorten the acute stage of the severe oph-
thalmy, by  the free  employment  of the
antiphlogistic treatment, and the  use of
mild*  emollient, topical remedies.
  If this plan of treatment  answer the
wishes of  the practitioner,   (continue*
Scarpa) as  in the  majority  of cases it
does, the incipient collection of coagulat-
ing lympK, at the bottom of the anterior
chamber of-the aqueous humour, not only
ceases to augment,  but, also, in propor-
tion as the severe ophthalmy disappears,
the absorbent system takes up the hetero-
geneous  fluid extravasated in the eye,
and the white, or yellow speck, shaped
like a crescent, situated at the bettoin of
the  anterior chamber, gradually dimin-
ishes, and  is at  last  entirely dispersed.
Janin  considered  the  infusion  of the
flowers of  mallows, applied  to the eye
that is inflamed and affected with this dis-
ease, as a specific resolvent  in these cir-
cumstances.  (Jlfem. et Obs.  suri'CEil, p.
405;) but, it  is  now  known, that every
topical  emolient  application,  provided it
be conjoined with such internal antiphlo-
gistic treatment, as  is the most proper for
repelling  the  ficute stage of the severe
ophthalmy,  produces quite as good  an
effect as  this  infusion.    Simple  warm
water produces  the same - benefit.   " A
young girl, (writes the celebrated  prac-
titioner Nannoni) was struck in the eye by
an ear of corn.  An inflammation was the
consequence,  which produced  a  white
pus of a  semilunar shape, apparently be-
hind the cornea, without  a possibility of
judging, whether the matter was actual-
ly  situated  between the  laminae of that
membrane,  or in the  anterior chamber.
Hence, I was asked whether  it might not
be evacuated by an  incision, particularly,
as the patient complained of great pam
in the eye,  and eye-brow.  She  was in
the hospital; and in the presence of Dr.
Lulli, and several students in surgery,  I
saiii that  the  pain  of which the patient
complained, was  not  occasioned by the
pus itself, but the cause which produced
it.   This cause was inflammation, which
probably  would  be increased by making
a larger opening for the external air, than
what it has to the  internal  parts,  while
the external ones remain  entire.  By fo-
menting the eye and forehead with warm
water, the  inflammation  subsided, and
the pus disappeared.  We have so often
witnessed the fact subsequently, that we
can idso extol the simplicity of the treat-
ment.'   Such, in short is the happy ter-
mination of an hypopium, whenever the
disease  is properly  treated at its com-
mencement, and  the acute stage of the
severe  ophthalmy   has  been promptly
checked,  and  repelled by  internal anti-
phlogistic meaiib,  and eniolient applica-
tive* to the eye.  But, in consequence of
the inflammatory period  of the  severe
ophthalmy  having  resisted  in  an un- 
                                     HYPOPIUM                              123

   common manner the best means, or be-  intervals, the vapours of the spir. ammon.
   cause such  means have  been employed  comp. mentioned in the article Ophthalmy,
   too late, it sometimes happens, that the  may be applied, and recourse had again
   coagulating  lymph, effused  in the eye,  to  a blister on the nape of the neck.
   and collected in the anterior chamber,  is  When the extreme sensibility  of the eye
   so abundant, even after the acute stage of  is overcome, the simple vitriolic collyriura
   the ophthalmy, that it  continues *for a  must be used again, strengthening it after-
   long time to cloud the eye, and intercept  wards by the addition of a few drops of
   vision.  Scarpa  has often  seen patients,  camphorated spirit of wine.   Under such
   especially  paupers,  who  from indolence,  treatment,  proceeds Scarpa, the surgeon
   negligence, or ill treatment, have remain-  may observe, that,  in proportion  as the
   ed, a long time after the cessation of the  chronic ophthalmy  disappears, and the
   inflammatory stage of  ophthalmy, with  action of the absorbents is re-excited, the
   the anterior chamber almost entirely fill-  tenacious matter of the hypopium divides
   ed  with the  glutinous  matter of hypo-  first into several small masses; then dis-
   pium.   When  the inflammation  cease*,  solves still  further; and, afterwards, de-
   these unhappy persons wander about the  creases in  quantity; depending towards
   streets almost quite indifferent, and with-  the inferior segment of the cornea ; and,
   out complaining of pain,  or any other in-  finally, vanishing altogether.  But Scar-
   convenience, than the difficulty of seeing  pa accurately observes, that the surgeon
   with the eye  affected.   In this  second  cannot always  expect to be  equally suc-
   stage of the ophthalmy, the resolution of  cessful, whether the disease occur during
   the hypopium obviously  cannot  be ac-  the first,  or second stage of violent acute
   complished by the same means, nor with  ophthalmy, if the tenacious lymph, sud-
   equal celerity, as in the first   At this cri-  denly extravasated in the interior  of the
   sis, the  great quantity, arid density 'of the  eye, prevail in such quantity, as not only
   glutinous matter extravasated, and the  to fill, but strongly distend, the two cham-
   atony of the vascular system of the eye,  bers of the  aqueous  humour, and the cor-
   make it necessary to give nature  suffi-  nea  in particular.   Notwithstanding the
   cient time, to dissipate the  thick,  tenaci-  most skilful treatment, in this state of the
   ous matter ofthe hypopium, and, at length,  complaint,  the unpleasant complication
   to dispose it to be insensibly absorbed  is  often followed by another inconveni-
   with the aqueous humour which  is con-  ence, still worse than the  hypopium it-
   tinually  undergoing a renovation.  Hence,  self; viz. ulceration, opacity, and burst-
   it is right, (says Scarpa) to adopt these  ing of the cornea, at that point of its cir-
   means, which are best calculated to invi-  cumference, or centre opposite the pupil,
   gorate the debilitated tone of the vascular  where there is the smallest resistance to
   system of the eye,  more especially the  the pressure.
   lymphatics.  This requires  more or less    The ulceration of the cornea ordinarily-
   time, according as the patient is advanc-  takes place  with  such celerity, that the
\   ed in years, of a relaxed fibre, and weak;  surgeon seldom  has  time to prevent it.
   or a young man of good constitution.       As soon as  an aperture has formed, the
     However, in the second stage of violent  excessive abundance of coagulating lymph,
   acute ophthalmy, complicated with hypo-  contained in the  eye, (sometimes named
   pium, the  surgeon,  according to Scarpa,  empyema oculi) begins to escape through
   should limit his efforts to the removal of  it, and a degree of relief  is experienced.
   every thing, which may  irritate the eye,  But, this melioration  is not of long con*
   or be  likely to renew the inflammation;   tinuance ; for, scarcely is  the glutinous
   and he should only employ such means, as  fluid e^cuated, that distended the whole
   are conducive to the resolution of the se-  eye, and especially the cornea, when it is
   cond inflammatory  stage, depending on  followed by a-portion of tlie iris,  which
   relaxation of the conjunctiva and its ves-   glides through  the  ulcerated aperture,
   sels, and such  remedies   as tend, at the   protrudes externally, and constitutes the
   same time, to invigorate the action ofthe   disease termed,  prolapsus  of the  iris.
   absorbents.  Therefore, in this state, he   (See Iris,  Prolapsus of)   But, if  in such
   ought first to examine carefully the de-   an emergency, the  cornea already  ulce-
   gree of irritability in the eyeaffected with   rated, opaque, and  greatly  deranged  in
   the  hypopium, by  introducing, between   its organization, should not immediately
   the eye and eyelids,  a few drops of vitri-   burst, the surgeon is then constrained by
   olic collyrium, containing the mucilage  the violence of the symptoms, depending
   of quince-seeds.   Should the eye seem too   on the prodigious distention of the  eye-
   itrongly  stimulated  by  this application,   ball,  to make an artificial opening in this
   it must not be used, and little bags of  membrane,  in order to relieve the im-
   warm mallows with a few grains of cam-   roense constriction, and even the danger
   phor are  to be  substituted for it.  In fee   in which life is placed.  The practitioner 
124            I X C
IXC
Will do this the more readily,  as, in such
circumstances,  there is little hope of pre-
serving the organ of vision. Scarpa adds,
that the pain" in the eye, and whole head,
is often so severe in this case, as to cause
delirium.
  Were there the least chance of restor-
ing, in  any degree, the transparency of
the cornea, and the functions of the or-
gans of vision, after opening the cornea,
it would certainly be more prudent to
make the opening at the lower part of
this membrane, as is practised in the ex-
traction of the cataract.  But, in the  case
of empyema of the eye, now considered,
in which  the cornea is universally  me-
naced  with ulceration and opacity,  and
seems ready to  slough, there is no hope of
its resuming its transparency at any point.
The best, and most expeditious, method
of relieving the patient from the terrible
pain, which he suffers, is, according to
Scarpa, to divide  the centre of the cor-
nea withti small bistoury to the extent of
a line and  a  half; then to raise with  a
pair of forceps the little flap, and  cut it
away all round with one  stroke of  the
scissars, so as to  make in  the  middle of
this membrane an  opening of about the
size of a lentil-seed.
  The most fluid  part of the matter, dis-
tending  the eye,  immediately  escapes
through this  opening, the lips of which
cannot  close, like  those of  a simple in-
cision.  Successively  afterwards, the co-
agulating lymph, and the chrystalline lens,
take the same course, and also, in a few
days, the vitreous humour.  The surgeon
should  refrain from promoting the escape
of  the latter by strong pressure  on the
eyeball; experience proves, that, msuch
cases, it  is best to allow it to  flow out
spontaneously.                  .
  Immediately  after the operation, the
surgeon must cover the eye with a bread
and milk poultice, which is to be  renew-
ed every  two hours, not neglecting tlie
ut,e of such general remedies, as are cal-
culated, to check the  progress of acute
inflammation,  and to  quiet the alarm of
the nervous  system.  In proportion as
the interior of  the eye suppurates, the
eye-ball gradually diminishes, shrinks into
tne orbit, and at length cicatrizes, leaving
things in a favourable state for the appli-
cation of an artificial eye.
  However, Scarpa infers from the whole
of what has just been said, that making
an incision into the  cornea is as danger-
ous, and useless, in the  case of hypopium
ordinarily met with in  practice, as it is
necessary in the instance of empyema of
the eye, attended with  the  aggravating
symptoms  above-mentioned,  and irreme-
diable opacity of the cornea.
  The foregoing remarks, which are some
of  the best ever offered on the subject,
were first published  by Professor Scarpa
in Saggio di Osservazioni e d* Experience,
sulle PrincipaU Mallattie degli Occhi;  Ve-
nezia, 1802.  Another excellent writer on
hypopium is Richter :  see Anfangsgrtmcle
der 'IVwidarzneykunst, Band. 3.1795. Con-
sult also Essays on the morbid Anatomy of
the Human Eye: by J.  Wardrop, Chap. 6.
Edinb. 1808.
   HYSTEROTOMIA. (from *a-Tt%*t the
womb, and rtfMot, to cut.) See Cesarean
 Operation.
I.
    rIPERFORATE HYMEN.   See  Va-
    gina.
  INCARCERATION,  (from incarcero,
to  confine.)  This  term  is usually.ap-
plied to cases of hernia,  in the same sense
as strangulatiou.  When the viscera are
pressed  upon  either . by  the  opening
through which they protrude, or  by the
parts themselves  within the hernial  sac,
in such a degree, that the course of the
intestinal matter to the  anus is obstruct-
ed, and nausea, sickness,  pain, and  ten-
sion of the swelling and  abdomen, &c.
are occasioned, the rupture is said to be
affected with incarceration, or strangula-
tion.
  According to Professor Scarpa, how-
ever,  an incarcerated, and a strangulated
hernia, do not  imply exactly the  same
tiling.   In the first  case,  says  he, the
course of the intestinal  matter is  inter-
rupted,  without  any  considerable im-
pairment ofthe texture, *or vitality of ihe
bowel   On the contrary, in the strangu-
lated hernia, besides  the obstruction to
the course of the fecal matter, there  is
organic injury of the coats of the intestine,
with loss of its vitality.   The bowel, that
is merely incarcerated, resumes its func-
tions immediately  it  is replaced in the
abdomen ; while  that, which  is  truly
strangulated, never returns to its natural
state.  (See  Scarpa's Traite des Hernies,
p. 251.)
  This distinction, however,  which Scar-
pa has drawn, is  by no means  generally 
INC
IN F
125
adopted, incarceration, and strangulation
being used as synonymous terms.
  INCISION, (from  incido, to  cut.)  A
wound made with a sharp cutting instru-
ment.
  INCONTINENCE  OF  URINE.  An
inability of the bladder to retain this fluid,
which should not be discharged without
the concurrence of  the will.  See  Urine,
Incontinence of.
  INDURATION,  (from induro, to har-
den.)  A morbid hardness of any part.
  INFLAMMATION,  (from  inflammo,
to burn.)  By the term,, inflammation,  is
generally understood, the state of a part,
iii which it is painful, hotter, redder, and
somewhat more turgid, than it naturally
is; which topical symptoms, when pre-
sent in any considerable degree, or when
they affect very sensible parts, are attend-
ed with fever, or a general  diseased ac-
tion of the system. (Burns.)
   The susceptibility of the  body  for in-
flammation is of two kinds;  the one ori-
ginal, constituting a  part of the  animal
economy, and beyond the reach of human
investigation ; the other ucquired from the
influence of climate,  habits  of life, and
state of the mind over  the  constitution.
 (Hunter.)   The first kind of susceptibi-
lity,  being innate, cannot be diminished.
by art; tlie  second may  be lessened by
 the  mere  avoidance of  the  particular
 causes, upon which it depends.
   Inflammation may, with great proprie-
 ty, be divided  into the  healthy and un-
 healthy.  Ofthe  first, there  can only be
 one kind; ofthe second, there must be
 an infinite number of species,  according
 to the peculiarities of different constitu-
 tions, and the nature of diseases, which
 are numberless.  (Hunter.)  Inflammation
 may also  be divided into the acute and
 chronic.   This  division of the  subject  is
 one of the most ancient, and seems  to
 have obtained the sanction of all the best
 surgical  writers.  Healthy inflammation
 is invariably quick  in  its  progress, for
 which reason,  it must always rank as an
 acute species of the affection.  However,
 there are numerous inflammations, con-
 trolled by a diseased principle, which are
 quick in their  progress, and are, there-
 fore to Ixj considered as  acute.  Chronic
 inflammation,  which we shall  treat  of,
 when we come  to the subject of tumours,
 is always  accompanied  with  a diseased
 action.

       PRINCIPLES OF INFLAMMATION.

    There is much foundation for believing,
 that  healthy  inflammation  is invariably
 an homogeneous process, obedient to  or-
 dained principles,  and,  in similar Consti-
tutions*,  similar structures,  and  similar
situations, uniformly assuming the same
features.   If  experience reveals to us,
that he~e  it is commonly productive  of
certain  effects, and there  it  ordinarily
produces different ones, the  same  un-
bounded  source of wisdom communicates
to the mind a knowledge,  that  there is-
some difference in the tone of the consti-
tution, 9r in the structure or situation of
the parts affected,  assignable as the cause
of this variety.   The nature of the excit-
ing cause can have no share in modifying
the appearances of phlegmonous inflam-
mation, whether this be occasioned by the
application of heat, or of mechanical vio-
lence to the body.   Healthy inflammation
is always the same in  its nature,  and  all
the influence, which the  exciting causes
can have, is proportioning the degree of
inflammation to their own  violence.  A
modern author  (Dr. Smith, in Med. Com-
munications, Vol. 2.) makes the  nature of
the exciting cause one principal  ground
of the specific  distinctions in inflamma-
tion,  and, with  good  reason,  when  he
takes into the account the actions of mor-
bid poisons, and the  qualities of disease
in general.
   The  attentive  observation of experi-
ence, the only solid basis of all medical,
as well as other, knowledge, has inform-
ed the practitioner, that parts, which from
their vicinity to the source of the circula-*
tion, enjoy  a   vigorous circulation  of
blood through  them, undergo inflamma-
tion more favourably and  resist disease
better, than other parts, of similar struc-
ture, more remote from the heart.  The
lower extremities are more prone to  in-
flammation, and disease in  general, than
parts about  the  chest; when inflamed,
they are longer in getting well; and the
circumstance  of  their   being depending
parts, which retards the return of blood
through the veins, must also increase the
backwardness  of  such parts in any salu-
tary  process. (Hunter.)  Wealthy inflani--
 ination is of a pale red; when less healthy,
 it is of a darker colour; but, the inflam-
 ed parts will, in every constitution, par-
 take more of the  healthy red, the nearer
 they are to the  source of the circulation.
 (Hunter.)
   Inilammation, when situated in highly
 organized and very  vascular  parts,  is
 more disposed to take a prosperous course,
 and is more  governable by art,  than  in
   * Here strength and  weakness are al-
 luded to; for, it is impossible that heal-
 thy inflammation should prevail in a dis-
' cased constitution.
• 
126
INFLAMMATION.
parts of an opposite texture.   The nearer
also such vascular parts are to the heart,
the greater will be their tendency to do
well  in inflammation.  (Hunter.)  Hence,
inflammation of  the  skin, cellular  sub-
stance, muscles, &c. more frequently ends
favourably, than  the  same  affection of
bones,  tendons,  fasciae,  ligaments, &c.
It is also more manageable by surgery;
for those parts of  the body, wtufh are not
what anatomists  term  vascular, seem to
enjoy only inferior powers of life,  and,
consequently, when excited in a preterna-
tural degree, frequently mortify.
   But, inflammation of vital parts, though
these may be  exceedingly  vascular,  can-
not go on so favourably, as in other parts
of resembling structure, but, of different
functions; because,  the  natural  opera-
tions of universal health depend so much
upon the sound condition of such organs.
(Hunter.) The trutli of  this observation
is illustrated in cases of  gastritis, perip-
neuinony, £e.
   All new-formed parts,  not originally
entering into the  fabric of the body, such
as tumours,  both  of the encysted and sar-
comatous kinds, excrescences, &c. cannot
endure  the  disturbance  of inflammation
long, nor in  a great  degree.  The vital
powers of such parts are weak, and when
irritated by the pressure of inflammation,
these adventitious substances are some-
times removed by the lymphatics,  but
more commonly  slough.    This   remark
applies  also  to substances generated as
substitutes for the original  matter of the
body; for instance, granulations  and cal-
lus.   The knowledge of this fact, leads
us to a rational principle of  cure  in the
treatment of several  surgical diseases.
Do we not here perceive the cause,  why
very large wens are occasionally  dispers-
ed by the application of urine, brine,  and
similar  things, which  are  now in great
repute, on this account, with almost every
one out of the profession ?  How many
verrucx, wrongly suspected  to originate
from  a  syphilitic cause, are diminished
and cured by a course of mercury !   It is
the  stimulus of this mineral upon the
whole system, that accomplishes the de-
struction of these  adventitious substances
—not its antivenereal quality.  Topical
stimulants would fulfil the-same  object,
not only with greater expedition, but with
no injury to the g- neral health.
  In  strong constitutions,  inflammation,
cxteris paribus, always proceeds more pro-
pitiously, than in   weak ones; for, when
there is much strength, there is little ir-
ritability.   In weak  constitutions,  the
operations of inflammations  are backward,
notwithstanding   the part,  in which  it is
seated, may, comparatively  speakiug, pos-
 sess considerable organization, and  pow-
 ers of life. (Hunter.)
   Healthy inflammation,  wherever situ-
 ated, is always most violent on  that side
 of the  point  of inflammation,  which, is
 next to the external surface of the body.
 When  inflammation attacks the socket
 of a tooth, it does not take  place on the
 inside of the  alveolary process, but to-
 wards the  cheek.  When  inflammation
 attacks the  cellular substance, surround-
 ing the rectum, near the  anus,  the affec-
 tion usually extends itself to the skin of
 the buttock, leaving the intestine perfect-
 ly sound,  though  in contact with tiie  in-
 flamed part.  (Hunter.)
   We may  observe the influence of this
 law in the fistula lachrymalis, in diseases
 of the frontal  sinuses, and  antrum, and,
 particularly, in  gun-shot wounds.  Sup-
 pose a ball were to pass into the thigh, to
 within an inch of the opposite side of the
 limb, we  should not find, that inflamma-
 tion should be excited along the  track of
 the  ball,  but, on the  side next  the skin
 which had not been hurt   If a ball should
 pass quite through a limb, and carry into
 the wound a piece of cloth,  which lodges
 in the middle, equidistant from the two
 orifices, the  skin, immediately  over the
 extraneous  body, would  inflame, if the
 passage of  the ball  were superficial.—
 (Hunter.)  Mr. Hunter compared  this law
 with the principle, by which vegetables
 approach the surface of the earth; but,
 the solution of it  was even  too arduous
 for his strong genius and penetration.
   We  see three very remarkable effects
 follow the prevalence of inflammation;
 viz. adhesions of parts of the body to each
 other; the formation of pus, or suppura-
 tion ; and ulceration, a process, in which
 the lymphatics are  more concerned than
 the blood-vessels.   Hence, Mr. Hunter
 termed the different stages of inflamma-
 tion, the adhesive, the suppurative, and the
 ulcerative.
  All parts of the body  are not equally
 liable  to  each of  the preceding conse-
quences. (Hunter.)
  In the cellular membrane, and  in  the
circumscribed cavities, the adhesive stage
takes place more readily, than the others
suppuration may be said to follow next in
order of frequency; and lastly ulceration.
  In internal canals, on the inner surfaces
of the eyelids, nose, mouth, and trachea,
in the air-cells of the lungs, in the oeso-
phagus, stomach, intestines, pelvis of the
kidneys, ureters,-bladder, urethra, and in
all the ducts and outlets of the organs of
secretion,  being what are termed  mucous
membranes, the suppurative inflammation
comes  on more readily,  than either  the
adhesive, or the ulcerative stage,  Adhe-
• 
INFLAMMATION.
 1 "**
■ lz<
Rions, which originate from the slightest
degree of inflammation in other situations
and structures, can only be produced by a
violent kind in the above-mentioned parts.
Ulceration  is more frequently met with
upon  mucous surfaces,  than  adhesions.
(Hunter.)   The  cellular membrane ap-
pears to be much more susceptible of the
adhesive inflammation, than the  adipose,
and  much more readily passes into the
suppurative.  (Hunter.y Thus we see the
cellular substance, connecting the muscles
together, and the adipose membrane  to
the muscles,  inflaming,  suppurating, and
the matter separating the muscles from
their lateral connexions,  and even the  fat
from  the muscles, while the latter sub-
stance and the  skin are oidy  highly  in-
flamed.  (Hunter.)   But,  it must be al-
lowed, that in situations where fat abounds
we very frequently meet with abscesses.
This  is so much the case, that fat has been
accounted  a more frequent nidus for col-
lections of matter, than the cellular sub-
stance.  (Bromfleld.) Abscesses are par-
ticularly liable to  form in the neighbour-
hood of the anus, mamma, 8cc.  We have
mentioned above  the fat's  being  highly
inflamed; an expression not strictly true.
Fat has no vessels, principle of life, nor
action of its own; consequently, we can-
not suppose it can itself either inflame, or
suppurate.   We know, that it is itself a
secretion,  and  when an  abscess forms in
it, we understand, that the mode of action
in the vessels,  naturally destined  to  de-
posit fat, has been altered to that adapted
to the formation of pus.   When we speak
of the fat being inflamed; we imply, that
the membranous cells, in which it is con-
tained, and by  which it is  secreted,  are
thus affected.
   The deeply-situated parts of the body,
more especially the vital ones, very readily
admit of the adhesive stage of inflamma-
tion.   The circifmstance of deeply seated
parts not so readily taking on the suppu-
rative stage of inflammation, as the super-
ficial ones do, is strikingly  illustrated in
cases of extraneous bodies,which, if deeply
lodged, only produce the adhesive inflam-
mation  By this process a cyst is formed,
in which they  lie' without much incon-
venience, and they  may even gradually
change their situation, without disturbing
the parts, through which they pass. But,
no sooner do these same bodies approach
the skin, than abscesses immediately arise.
 (Hunter.)
   All inflammations, attended with dis-
ease.partake of some specific quality, from
which  simple  inflammation is entirely
free.   When the  constitution allows the
true  adhesive and suppurative stages to
occur,  it is to be  regarded  as the most
Jjealthy.  Were  it in an opposite state,
 we should see the very same irritation ex-
 cite some  other kind  of inflammation,
 such  as  the erysipelatous, scrophulous,
 &c.  (Hunter.)
   In specific inflammations, the position,
 structure, and distance ofthe part affect-
 ed from the source of the circulation, as
 well as from the surface ofthe body, seem,
 also to have as much  influence as in cases
 of common  intkimmation.  Upon this point,
 I feel conscious of being a little at variance
 with what Mr  Hunter has stated; but the
 undecided manner  in which he expresses
 himself, not less  than the following  reflec-
 tions, encourages me.not to desert my own
 ideas.  We see  that venereal eruptions
 sooner make  their appearance upon the
 chest and face, than upon the extremities.
 No organized part can be deemed exempt
 from the attack of common inflammation ;
 many  appear to he totally insusceptible of
 the venereal.  We know, that scrophulous
 diseases ofthe superior extremities take a
 more favourable course, require amputa-
 tion less frequently, andget well oftener
 than when  situated  in !€ne inferior ones
 (Ford.) The venereal disease makes more
 rapid  advances in  the skin  and throat,
 than in the bones and tendons;  we often
 see it producing a  specific inflammation,
 and an enlargement  of the superficial
 parts of the tibia, ulna, clavicle, cranium,
 8cc. while other bones,  which are covered
 with a considerable quantity of flesh, are
 very rarely affected.  Gouty inflammation
 is prone to invade  the small joints, tiie
 rheumatic the large ones.

 SYMPTOMS AND NATURE OP HEALTHY INHA^
         MATION, OK PHLEGMON.

   Redness, swelling, heat, and pain,  the
 four principal symptoms of phlegmonous
 inflammation,  have  been accurately no-
 ticed  by  Celsus*   If we refer to  any
 writer on this interesting point of surgery,
 we shall And the  above symptoms enu-
 merated as characterizing phlegmon.  In
 short,  this term is usually applied to a
 circumscribed tumour .attended with heat,
 redness, tension, and a throbbing pain.
 These are the first appearances observed
 in every case of the phlegmon; and when
 they are slight, and the part affected is oi
 no great extent, they are commonly very-
 little, and sometimes no apparent, influ-
 ence on the general  system.  But, when
 they are more considerable, and the inflam-
 mation becomes  extensive, a  full,  quick.


   * Notx verd  inflammationis sunt qua-
 tuor, rubor, et tumor, cum ca^ore  et do-
 lore,  lib. 3. cap.  10. 
128
INFLAMMATION.
and generally a hard pulse,  takes place,
and the patient, at the same time, com-
plains of universal heat,  thirst, and other
symptoms of fever.  (B.  Bell.) While the
inflamed part becomes red,  painful, and
swelled,  its functions are also impaired.
The same degree of inflammation is said
to produce  more swelling in soft parts,
and lees in  harder ones.   (Burns.)
  Though  the  redness, swelling, throb-
bing,  tension,  and  other symptoms of
phlegmonous inflammation, are less mani-
fest, when the affection is deeply situated,
yet they certainly exist   When persons
die of peripneumony, or inflammation of
the lungs, the air-cells of these organs are
found crowded with a larger number of
turgid blood-vessels, than in the healthy
state, and of course the parts must appear
preternaturally red.  Coagulating lymph,
and even blood,  are  extravasated in the
substance of the viscera, which become
heavier, and feel more solid.   (Baillie.)
  The extravasation of coagulating lymph
which is one of the chief causes of the
swelling, is also  one of the most charac-
teristic signs of phlegmonous inflamma-
tion.
  Some writers (Smith,  Med. Common.)
have confined the seat of phlegmon to the.
cellular membrane; but, this idea is pro-
bably an erroneous one. Had such authors
duly discriminated the nature of common
inflammation, they  would have  allowed,
that this affection existed, wherever the
blood vessels appeared to  be more nume-
rous, and enlarged,  than in the natural
state, accompanied  with an effusion of
coagulating lymph, whether upon the sur-
face of a membrane, or a bone, or into the
interstices  of the cellular substarce, and
attended with acute pain, and a throbbing
pulsation in the part affected.
  Before proceeding further into the con-
sideration of inflammation, it seems pro-
per to treat oi causes.

            ME MOTE CAUSES.

  The remote causes of inflammation are
infinite in number; but, very easy of com-
prehension, because only divisible  into
two general classes.  The first  includes
all such agents as operate by their stimu-
lant or  chemical qualities;  for  instance,
cantharides, heat, &c  The second  class
of causes are those, which act mechanical-
ly, such as bruises, wounds, &c.  After
this statement, it seems quite unnecessary
to give a detail  of each particular remote
cause.*
  * Those,  who  are curious, may see  a
list of remote causes in Pearson's Princi-
pies of Surgery, p. 15.
  Fevers often sqem to become tlie remote
causes of local  inflammation.  In other
instances, inflammation  appears  to  arise
spontaneously, or, as 1 should rather say,
without any perceptible  exciting cause.
  The principle  on which the application
of cold to a part becomes the remote cause
of inflammation, is not decidedly known.
A modern author offers  the  following ex-
planation, in lieu of those founded on the
doctrines of cold being a stimulus,  and
a sedative cold may operate on a part in
three  different ways.  First, it  may be
applied in such a degree,  and for such a
length of time,  as to destroy the vitality
of tnepart directly;  in which case, sloughs
are formed.  Secondly, it may be applied
in a  less degree, or for a shorter time;
and afterwards a stimulant,  such as heat,
may be applied,  which will excite inflam-
mation.  The production of inflammation
by any agent,  depends in  a great degree
upon  the suddenness of the operation of
the ageat, which excites it; for a quantity
of stimulus, which, if  suddenly applied,
would produce inflammation, may be ap-
plied   slowly with  impunity. Hence, it
results, that any give*  stimulant  must
more   easily produce  inflammation in a
part, which has  a low action, &c. than in
one having a vigorous action, &c. Hence,
very slight stimuli will  induce inflamma-
tion in parts which have been weakened by
cold.   Thirdly,  a part  sympathises very
much with the contiguous ones.  If a part
be weakened by having its action reduced,
and if then the debilitating  cause be re-
moved, the action of the  part will be in-
creased  from sympathy with the neigh-
bouring acting parts.  But,  as the action
ought to be *ery little, the power being
small, inflammation must arise  from the
action being increased beyond the power.
We ought, therefore,  in this case, to di-
minish the  action  of  the  neighbouring
parts,  in order to prevent their extending
their  action to a part,  which is not able
to bear it  without becoming  diseased.
(Burns.)

           PBOXIMATE CAUSE.

  Numerous opinions have  been enter-
tained upon this   subject;  but, almost
every theory has been built upon the sup-!
position of there being  some kind of ob-
struction ip the inflamed part.
  While the circulation of the blood was
unknown, and'the hypothetical notions of
the power of the liver, in preparing and
sending forth,  this fluid,  continued  to
prevail,  it  is not  astonishing  that tiie
theories of physic should be exceedingly
imperfect.   So fully persuaded were phy-
sicians of the existence and influence of 
INFLAMMATION.                           129
different humours and spirits, and so little
did-they know of the regubr and constant
motion of the blood, that they believed in
the possibility  of depositions  and con-
gestions of the blood, the bile, or lymph ;
and acknowledged these as the  cause of
inflammation.   Their anatomists taught
tliecn, and their professors of physic sup-
ported the opinion, that the liver was the
centre ofthe vaseular system, from which
the blood  went forth by day to the ex-
tremities,  and returned again by  night.
If then any peccant matter  irritated the
liver, the  blood was sent out more forci-
bly ; and if, at the same time, any part of
the body were weakened, or otherwise dis-
posed to receive a greater quantity of flWd
than the rest, then a swelling was produ-
ced by the flow of humours to this place.
Fluxions,  or flows of humour to a place,
might happen either from weakness ofthe
part which allowed the humours to enter
more abundantly, or from  the place at-
tracting the humours, in consequence of
the application of heat or other agents.
(Burns.)
   The peculiar nature of  the  swelling
thus occasioned was supposed, by the an-
cients, to depend upon the kind of humour.
Blood produced the true phlegmon, bile,
erysipelas, Sec.
   The ancient physicians also entertained
an idea, that the blood and humours might
slowly stagnate  in^a part, from want of
expulsive  power, and this  affection was
termed a congestion,  while the expression
fluxion or defluxion was used to denote any
swelling arising  from the sudden flow of
humours from  a distent part.   The first
was formed gradually without much pain,
or the feeling  of pulsation, and run its
course slowly: the second appeared sud-
denly, was very painful, had a pulsatory
feel,  and was rapid in its progress. The
ancients, who supposed that the blood had
very little motion, and that its course could
be easily  directed or changed, recom-
mended bleeding from some part which
was remote from a recent inflammation,
by which  they imagined  that the current
of blood was altered, and a revulsion made.
A revulsion was also made, by raising  a
tumour in some other part,  by  means ^ of
ligatures,  cupping-glasses, &e. or by {jiv-
ing nature an opportunity of discharging
the humours from distant parts,  by  ap-
plying leeches  or blisters.   Hence si-
napisms were  applied to the feet, in dis-
ease of the superior  parts.  (Burns.)
   When blood was drawn from the vicinity
ofthe fluxion, or congestion, the mode was
called derivation which only differed from
revtdsion in the distance to* which the hu-
mour was drawn being less.   ( Burns )
   I shall not enter further into an account
     Vol.  II.
ofthe practice of the ancients in the treat.
ment of inflammation ;  but shall refer the
reader to what Mr. Burns has written on
the subject.  Our present object is only to
trace the leading doctrines, which have at
different times prevailed, respecting the
proximate causes of inflammation.
  From  the theories of fluxion and con-
gestion, which  were quite  incompatible
with the haws of the  circulation  of the
blood, we turn our attention to the doc-
trine of obstruction.
  Boerrhaave inculcated. (Aph 375  et seq.)
that inflammation was caused by an ob-
struction  to the free  circulation  of the
blood  in the minute vessels, and this ob-
struction, he supposed.might he caused by
heat, diarrhoea, too copious flow of urine,
and sweat, or whatever  could dissipate the
thinner parts of the blood,  and produce a
thickness or viscidity of that fluid.  When
the lentor did not exist before the produc-
tion of inflammation, he imagined, that
the larger globules of  the blood, got into
the small vessels, and thus plugged them
up.  When, for instance, the perspiration
was stopped, the fluid, being  retained,
dilated the  vessels, and allowed some of
these mischievous globules to enter, and
produce  a-  more permanent obstruction.
This circumstance was  termed an error
loci, and was one ofthe chief causes  assign-
ed  for inflammation.  The obstruction,
whether caused by viscidity or an error loci,
was imagined to occasion a resistance to
the circulation in the part affected; hence
increased it in the other vessels, proving
an  irritation to the heart, and augment-
ing the force or attraction of the blood in
that part of the vessel  which was  behind
the obstruction.  This caused  heat and
pain, while the aecumul. t on ofthe blood
produced redness;  which three symptoms
are the essence of  the disease.  Besides
obstruction,  Boerrhaave also brought into
the account an acrimonious state of tlie funds,
which rendered resolution out ofthe quesJ
tion, and gangrene likely to follow. (Aph.
388.)
  The viscidity of the blood cannot be ad-
mitted as the proximate cause of  inflam-
mation ;  because we have no proof; that
this state ever exists; or, granting that
it did, it  would  not   explain  the  phe-
nomena.  Were a  viscidity to  occur, it
would exist in the whole mass of blood,
would affect every part of the body alike,
and could not be supposed to produce only
a local disorder.  How also could such a
lentor be produced by  causes which bring
on inflammation suddenly, without there
being time  for changes  of the fluids  to
 take place?  (Burns.)
   With regard to the doctrine of error loci,
or of red globules going into vessels,which
     R 
130
INFLAMMATION.
 did not formerly  transmit them,  the fact
 must be admitted, at the same time, that
 the conclusion is denied.   When the eye
 becomes inflamed,  the tunica conjunctiva
 is seen with its vessels full of red blood,
 which in health is not the case;  but this
 redness never appears until the inflamma-
 tion has commenced, and must, therefore,
 be considered as  an effect, not a cause
 Nor  can  this error loci  occasion  any ob-
 struction in these vessels ; for, if they be
 divided, the  blood flows  freely, which
 shews, that they are lar,<e enough to allow
 an easy circulation.  (Buiiis.)
   Boerrhaave's theory 01 obstruction was
 too circumseribed,  and too  mechanical;
 it reduced all inflammations to one spe-
 cies.   The only distinctions wh.ch  could
 have arisen, must have proceeded from the
 nature of the obstruction itself. This doc-
 trine couid never account for the action of
 many  specific  diseases and morbid poi-
 sons.   (Hunter.)
   As for the supposition of the co-opera-
 tion of" an acrimony of the fluids, the pro-
 portion of the saline matter of the blood
 has never been proved to be greater in
 this,  than in any  other state of the body.
 (Burns.)  Even were a general disorder
 of  tins kind  to be  admitted, no rational
 explanation of the proximate cause of lo-
 cal inflammation could be deduced from it.
   Dr.  Cullen attributed  the proximate
 cause of inflammation to a " spasm ofthe
 extreme arteries supporting an increased
 action in  the  course of  them."  This
 theory only differs from that of Boerrhaave
 in the cause which is assigned for the  ob-
 struoiion.  Some  causes of inequality in
 the distribution ofl the blood,  may throw
 an unusual quantity of it upon particular
 vessels, to which it must necessarily prove
a stimulus.  But, farther, it is probable,
 that to relieve the congestion, the vis me-
dicatrix naturae increases  still more the
 action of the vessels; and which, as in all
Other febrile  diseases, it  affects, by the
formation of a spasm on  their extremi-
ties."  " A spasm ofthe extreme arteries,
 supporting an  ir-creased  action  in the
eourse of them, may, therefore,  be con-
 sidered as the proximate cause of inflam-
mation; at least,  in all  cases not arising
from direct stimuli applied; and, even in
this case, the stimuli may  be supposed to
produce a spasm of the extreme vessels."
 (Cullen.)
  The inconsistencies in Cullen's theory
 are very glaring.  The congestion or ac-
cumulation of blood, which is  only an
 effector consequence of inflammation,  is
 set down as the cause ofthe spasm ofthe
vessels, to which spasmodic constrictions,
Cullen, strangely enough,  assigns  the
name  of proximate cause. The spasmodic
contraction ofthe extremities of the ves-
sels, instead of propelling the accumulated
quantity of blood, would render the pas-
sage of the blood from the arterial into the
venous system still more difficult.   Spas-
modic constriction of the small vessels is
so  far from being a satisfactory explana-
tion ofthe proximate cause of inflamma-
tion,  that even tying a large  vessel docs
not of itself bring on tiie affection.  I 'lile^-
mdn  is also attended with an effusion into
the cellular substance from the extremi-
ties of the arteries;  a  circumstance  not
easily explained upon the principle of ob-
structed circulation.  (Burns.)
   We shall now notice the celebrated, and
very  original, opinions, promulgated on
this subject by the famous John Hunter.
According to  him  inflammation is to be
considered only  as  a disturbed state of
parts, which requires a  new, but salutary
mode of action, to restore them  to that
state, wherein a natural mode of" action
alone is necessary.  From  such  a view of
the subject, therefore, inflammation in it-
self, is not to  be considered as a disease,
but as a salutary operation,  consequent
either to some violence, or some disease.
Elsewhere, the author remarks, the act of
inflammation is to be considered as an in-
creased action of the vessels, which, at
first,  consists  simply in an increase or
distention beyond their natural size  This
increase seems to depend upon a diminu-
tion ofthe muscular p"bwer of the vessels,
at the same time that the elastic power of
the artery  must  be  dilated in tlie same
proportion.  This is, therefore, something
more  than simply a  common  relaxation:
we must suppose it an action in the parts
to produce an  increase of size, to answer
particular purposes,  and this Mr. Hunter
would call  an act of  dilatation.  The
whole is to be considered  as  a necessary
operation of nature.   Owing to this dila-
tation, there is a greater quantity of blood
circulating in the part, which is according
to  the common  rules of the animal eco-
nomy ; for,  whenever a part has more to
do than simply to support itself, the blood
is there collected in larger quantity. The
swelling is produced by an extravasation of
coagulable lymph, with some serum ; but,
this lymph differs from the common lymph,
in consequence of passing through inflam-
ed vessels.  It  is this lymph which  be-
comes the uniting medium  of inflamed
parts ; vessels shoot  into  it; and it has
even the power of becoming vascular itself.
The pain proceeds from spasm.  The red-
ness is produced either by  the arteries
being more dilated than  the veins,  or  be-
cause the blood  is  not changed  in the
veins.  When  a  part cannot be restored
to health, after  injury,  by  inflammation 
INFLAMMATION.                          ,.J31
alone, or by adhesion, tlien suppuration,
as a preparatory  step  to the formation of
granulations, and the consequent restora-
tion  of the  part takes place.  The ves-
sels are nearly in the  same  state as in
inflammation ; but  they are more quies-
cent, and  have acquired a new mode of
action
  An increased action of the vessels is now
almost universally regarded as the proxi-
mate cause of inflammation. This opinion
is greatly supported from a review of the
several exciting  causes of the  affection,
which, being  in general  of an irritating
nature, must,  when applied to any living
or sensible parts, occasion a preternatural
exertion of the  vessels.  The method of*
cure, as we  shall presently see, tends  also
to confirm the general doctrine with re-
spect to the cause of inflammation.

StMPTOMS or  PHLEGMONOUS INFLAMMATION
          FURTHER CONSIDERED.

  The essential  symptoms are  redness,
swelling, heat, and pain.
  Redness.—This is manifestly  owing to
the increased quantity of blood in the in-
flamed part.   More blood must necessa-
rily be contained there, because the  ves-
sels, which previously conveyed this fluid,
are preternaturally distended,   and  the
small vessels,  which naturally contained"
only lymph,  are  now so enlarged as to be
capable of  receiving  red blood.  Many
have supposed, that the redness of com-
mon inflammation is partly occasioned by
the generation of new vessels.  This doc-
trine, however, seems  very questionable.
When coagulating lymph is extravasated
upon the surface of a wound,  an inflamed
membrane, Sec I think no one can doubt,
that the lymph often becomes  vascular, in
other words, furnished with new vessels.
But, in the extravasated lymph of a phleg-
monous  tumour, we  have no  evidence
shewing, that there is any generation of
new vessels.   Were the lymph to be  ren-
dered organized and vascular, the swell-
ing and redness  would probably be more
permanent,  and not admit, at least so ea-
sily, of resolution.   When adhesions form
between  two  inflamed surfaces, the or-
ganized substance, forming the connexion,
lives after tlie subsidence ofthe inflamma-
tion, and is a  permanent  effect.  It  was
probably  the enlargement of the small
vessels, which led to the  theory, that new
vessels are  formed in inflammation. It
has, however, been justly observed,  that
the  supposition  easily admits  of refuta-
tion ; for  heat, and many other  causes of
inflammation, operate  so  quickly,  that
there can  be no time for  the formation of
any new vessels; and, yet the redness is
as great, and the inflammation as pi rfect
in a  minute as in an hour or a day  after
the  application of the  exciting cause.
(Bums.)  Another reason, assigned for
the redness of inflammation, is that the
blood, after it has become venous, retains,
more or  less, its bright scarlet  colour.
(Hunter.)
  Swelling.—This effect arises from several
causes.  1. The increased quantity of blood
in the vessels.  2 The  effusion of coagu-
lating lymph, and deposition of new mat-
ter.   3. The interruption of absorption,
of late particularly noticed. (Soemmering
de Morb. Vas. Absorb.)
   Pain.—This  is observed  to be greatest
during  the diastole of  the arteries.  The
affection is probably owing to the unna-
tural state ofthe nerves, and not to mere
distention, as many have asserted.  Were
the latter cause a real one, the pain would
always be proportioned to it.
   Heat.—It  was formerly imagined  by
many,( Boerrhaave, Savage,&c.)who wrote
after the discovery of the circulation of
the blood,  that the heat was produced by
the attraction ofthe red globules, against
the sides of the vessels.  Modern philoso-
phy,  now,  however,  teaches  us,  that  a
fluid may flow, with the utmost velocity,
through a pipe, for  a thousand  years,
without producing a single degree of heat.
The most commonly received opinion now
is, that the production of animal heat de-
pends upon the difference in  the capacity
of arterial and venous  blood  for combin-
ing with caloric; and that in the minute
arteries, the blood is combined with cer-
tain substances, in consequence of which
its capacity is diminished,  and heat  is
given out.  But, when  the venous  blood
has been  freed from such substances  in
the lungs,  its capacity is increased, and
the heat, which  is given out by the de-
composition  of the air which we inspire,
is absorbed.  Now, if these things be ad-
mitted as facts,  the augmented heat of in-
flammation may be conceived  to  arise
from the increased velocity of the circula-
tion in  the p:u-t affected.   More blood is
transmitted into the minute arteries; the
capacity of  a  greater quantity  of this
fluid for heat is of course there necessa-
rily diminished, and more caloric is ex-
tracted.

APPEARANCES  OF THE  BLOOD IN  INFLAM-
                MATION.

   The blood, when taken out of the living
vessels, spontaneously  separates into two
distinct parts,  the serum and the crassa-
mentum.  The last is  a compound  sub-
stance, consisting chiefly of coagulating
lymph, and red globules, the most heavy 
132
INFLAMMATION.
ingredients in the blood.   Blood,  taken
away from persons affected with mfl.m-
mation, is longer in coagulating, and co-
agulates  more firmly, than  in otln-r in-
stances.  Hence, the  red  globules,  not
being so soon entangled in the lymph, de-
scend, by their gravity, more deeply from
its surface, which, being more or less di-
vested of the red colouring matter,~is from
its appearance termed the huffy coat, or
inflammatory crust.   The firmer and more
compact coagulation of  the lymph com-
presses out an unusual quantity of serum
from it, and the surface of the sizy blood
is often  formed into a hollow,  the edges
being  drawn inward.  (Hunter.)   These
changes in the blood are, in some cases, a
more infallible proof of the existence of
inflammation, than the state of the pulse
itself,  At the same time, it is probably
only a criterion of some unusual, operation
  going oii'in the system; for the blood taken
  om pregnant women is always found to
exhibit the above appearances. In peri-
toneal inflammation, the patient sometimes
seems to be  in the most feeble state, and
the pulse, abstractly  considered,  would
rather induce the practitioner to employ
tonics and stimulants,  than evacuations;
but, should the continuance or  exaspera-
tion of the disorder, or any other reason,
lead the surgeon  to use the lancet, then
the buffy coat, and the concave surface of
the blood, clear away all doubt concerning
the existence of inflammation.
  In  a few anomalous constitutions, the
blood, when  drawn, always exhibits the
above peculiarities.

    TERMINATIONS OF INFLAMMATION.

  Inflammation is  said to have three dif-
ferent terminations  or, in more  correct
language, we may say, that,  after this
process has  continued a certain time, it
either subsides  entirely,  induces  a dis-
position  in the  vessels to  form pus, or
completely destroys the vitality of the
part.
   When the  inflammation is to end in the
first manner, which is the most favourable,
the pain becomes less, the swelling  sub-
 sides, tlie fever, and every other symptom,
 gradually  abate,, till at last  the  part is
 wholly restored to its  natural size and
 colour.  There  is no formation  of pus,
 nor any  permanent injury  of structure.
 This termination of inflammation is term-
 ed by surgeons resolution.  It is fortunately
 the most common, as well as the most de-
 sirable manner,  in which  the affection
 ends.
   If however, notwithstanding the appli-
 cation of the usual remedies, the  several
 symptoms of heat, pain, and redness, in-
stead of diminishing, rather increase; if the
febrile symptom* are likewise augmented,
and the tumour gradually acquires a larger
size, turns soft, somewhat prominent in
the middle, or towards its most depending
part; if it should next  acquire a clear
shining appearance,  and  become  less
painful, the different symptoms of fever
being at the same time diminished, and a
fluctuation perceptible in the tumour, the
inflammation has ended in suppuration.
  The worst, but, happily,  the  least fre-
quent consequence of common inflamma-
tion,  is the death, or mortification, of the
part affected. The signs of this disastrous
event are a change  of colour in  the part,
•which, from being of a bright red, becomes
of a livid  hue ; small vesicles, filled with a
thin fetid serum, arise on its surface, and
air is plainly felt to exist in the disordered
situation.   The pain is, indeed, diminish-
ed; but the pulse sinks, while the tumour
is gradually changed  into a black,  fibrous
mass.
   These  are  the three most usual termi-
nations of inflammation. By many authors,
however,  anothe&disorder has been treated
of, as one in which inflammation is apt to
end,  viz.  scirrhus.   But, although  that
complaint may, perhaps, in,  a lew in-
stances, follow inflammation;  yet, it is far
from being a common consequence of it.
•Hence, although inflammatory  affections
may justly enough be mentioned as one of
the many exciting causes of scirrhus, yet
the consideration of this  disorder can
never with propriety, it is presumed, be
introduced into an account of inflamma-
tion. (B  Bell)
    Common  inflammation,  particularly
 when it affe<- .s glandular parts,  is  often
 observed  to leave  an induration  in the
 part.   We know very well,  that, when
 the testis has been  inflamed, a hardness
 of the epididymis frequently  remains af-
 terwards during life.  Such  indurations,
 however, are not  at all malignant, and,
 consequently ^ are very different iir  their
 nature, from what  is  implied  by a real
 scirrhus.

      TREATMENT OF  INFLAMMATION.

 Removal of the Exciting, or Remote Cause.

   After the description,  which we  have
 given  of inflammation, the reader may
 easily guess, that  the  grand principle to
 be observed in the treatment, is to endea-
 vour to lessen that immoderate action of
 the arteries, which is now  commonly set
 down as the proximate cause.
•"   The first circumstances to be attended
 to in all cases, in which resolution is to
 be attempted,  is the removal of all suxV 
INFLAMMATION.
233 .
exciting causes of the disorder as may
happen to  present themselves.   If the ir-
ritation of a splinter should excite phleg-
monous inflammation, who would not of
his own  accord extract the extraneous
body?
  Foreign substances in wounds frequent-
ly excite inflammation, and ought  to  be
taken away as speedily as possible; splin-
tered pieces of bone often give rise to the
affection,  and require removal: the head
of a  bone, being out of its place, may
press and inflame the part on which  it
lies;  and  who does not immediately see
Uhe propriety of putting it back into its
natural situation P  Such exciting causes
as these may oftentimes be detected and
removed at once, and this is doing a great
deal  towards the cure  of the inflamma-
tion.   Many of the e xciting causes of this
affection are only  of momentary  appli-
cation ; yet,  though they no longer exist,
the process of  inflammation must  follow
the  violence and irritation, which were
suddenly   produced,  and  still remain.
Hence, besides taking away, if possible,
the remote cause, it is proper to moderate,
 by other  means, the increased action of
 the vessels.

                Bleeding.

   If the doctrine which we have advanced
 be true, viz. that inflammation depends
 upon an  increased action of the vessels,
 and that  a greater quantity  of blood is
 impelled  into,  and circulates,through the
 inflamed part,  than  in the natural state;
 it follows that bleeding must be a prin-
 cipal  means of  relieving inflammation;
 because it lessens the action of the whole
 arterial system, and, of course, of that
 part which is undergoing  inflammation;
 and  because it  diminishes the quantity
 of blood transmitted to  the part affected,
 by lessening the whole mass in the circu-
 lation.
   Bleeding,  however,  is  often  misem-
 ployed, especially, when regarded as the
 only remedy for inflammation,  and  other
 steps are neglected.   The obstinacy and
 vehemence of the  process in weak con-
 stitutions  prove, that bleeding is not in-
 variably  proper.  When inflammation is
 complicated with  an unhealthy state of
 the alimentary canal,  blood should  be
 taken away  with great circumspection.
 A great  deal  of induration, with little
 pain and heat in the inflamed part; the
 probability of a long and copious  suppu-
 ration, as is tlie base in  many compound
 fracuires; and the dependence of the in-
 flammation  on  local weakness; are par-
 ticular instances, in which the practitioner
 should  be  sparing  of this  evacuation.
Bleeding is quite unnecessary when  the    ,
focal inflammation and symptomatic fever
are trivial,  when the patient is feeble or
very  old, and  when the  cause of  the
affection can be entirely removed.  (Rich-
ter.)
  On  the other hand, bleeding is highly
beneficial  in  all cases, in  which the  in-
flammation is uncomplicated with a mor-
bid state of the gastric system, is  consi-
derable in extent and degree, and attend-
ed with a good deal of ebrile disturbance.
The same is also strongly indicated, when
the part affected is  very sensible,  and
highly important, in regard to its office in
the system.  Hence, ophthalmy,  or  in-
flammation of the eye,  which is a most
sensible part, particularly requires  a free
evacuation of*  blood.  Hence, inflamma.
tion  of the  lungs, brain,  or stomach,
which  are  organs, the sound state of
which is  intimately essential  to the  re-
gular continuance of all the various ope-
rations in the  animal machine, particu-
larly  demands the employment of the
lancet; for, if,a successful effort  be not
promptly made to stop such inflammation,
death itself will, in  all probability,  be the
result.
   Bleeding is  likewise indicated, when
the  patient is young, robust, and  ple-
thoric ; when the cause of the .disorder
can neither be removed nor diminished,
and when there is a very strong motive
for wishing  to avoid the formation of
matter.  Inflammation of  the eye affords
an instance  illustrative  of the  truth of
the last observation; for, if suppuration
be allowed to take place in this  organ,
the common consequence is so serious a
destruction of  its internal structure and
organization, that the future  restoration
of sight is totally impossible.  Under such
circumstances as  we have specified, it is
frequently necessary to repeat  bleeding
several times.
   The efficacy of bleeding is greater, the
sooner it is practised, and the more sud-
denly the  blood is  evacuated.  Bleeding
near  the  part  affected  is  usually  more
effectual-  than when done in a remote
situation.  Hence, in inflammation  of the
eye or brain, it is deemed  most advanta-
geous  to take blood from the temporal
artery.
   The preceding remarks chiefly relate to
general bleeding; for, in phlegmonous in-
flammation, topical bleeding is scarcely
ever  improper. It is always a point highly
 worthy of the surgeon's  consideration,
 whether bleeding in or near tlie part will
 answer better,  than taking the blood from   i
 the general habit; for, certainly less may
 be removed in this  way, so as to have
 equal effect upon the part inflamed, and 
134                          INFLAMMATION.
 probably, upon every other disease that is
 relieved by  bleeding, and yet affect tlie
 constitution less. Although, in many cases,
 the general habit may be elieved by bleed-
 ing, vet the part affected will always re-
 quire  this evacuation  most.  That local
 bleeding has very considerable  effects on
 the inflamed part, is proved by the sudden
 relief, which leeches, applied in cases  of
 gout, produce. Bleeding by leeches, alone
 will also remove a tumour in  the  breast,
 haying all  the appearance of a scirrhus,
 which cannot be considered as  inflamma-
 tory,  so that topical bleeding extends its
 power further than the mere checking of
 inflammation.   Some part of its effect has
 been  imputed  to  sympathy.  (Hunter.)
 There are three modes of performing to-
 pical  bleeding; by cupping; by leeches ;
 and by dividing, or scarifying die dilated
 vessels leading to  the  inflamed part.
 Upon the head and fiice, leeches are com-
 monly employed; upon the  chest, either
 leeches or cupping; upon the abdomen,
 leeches; and upon the joints, either cup-
 ping  or leeches.  When  the  eye is in-
 flamed, leeches may either be applied to
 the adjoining temple ; or the dilated ves-
 sels of the conjunctiva may be scarified;
 or both methods may be adopted.   When
 the inflammation extends quite to the sur-
 face of the body, leeches are always most
 eligible, as their bite causes less irritation
 in inflamed  parts,  than the punctures of
 the scarificator, or the pressure  of the
 cupping glasses.

               Purging.

  The exhibition of mild laxative medi-
 cines,  and  saline purgatives,  is a prin-
 cipal means of diminishing inflammation.
 Purging doe* not produce  such  lasting
 weakness as is the consequence of  bleed-
 ing, and, consequently,  it is scarcely ever
 omitted, even when taking away blood  is
 deemed  improper.   Saline purges must
 lessen the quantity  of  circulating  blood,
 inasmuch as they increase the secretion
 from the intest'uial arteries.  Hence, they
 must  operate  beneficially  in the cure of
 local inflammation,  much  upon  the same
 principle as bleeding does.  Mr. Hunter
 was of opinion that purging lowers ac-
 tion,  without  diminishing strength,  by
 which we  are  probably to understand,
 without producing a very  lasting or per-
 manent loss of strength.  With respect to
mild  laxative medicines, none are supe-
rior to manna, rhubarb,  oleum ricini, and
the like; and of the saline purgatives,
which  are  in  general  preferable  to the
former ones, the natron vitriolatum, kali
tartarizatum, soda phosphorata, and mag-
nesia vitriolata, are  the best.   We mav
here  remark,  that besides  the  benefit,
which the local inflammation derives from
the judicious administration  of  purga-
tives,  the costiveness and  heat,  which
usually attend the symptomatic fever, are
also relieved by the same means.

         Nauseating Medicines.

   Medicines, which have the power  of
producing sickness, lessen for a time, the
action,  and even the general powers of
life.  This is in consequence of every part
of the body  sympathizing with the sto-
mach ;  and the effect may be very quickly
excited. Sickness lowers the pulse, makes
the small vessels contract, and rather dis-
poses the skin for perspiration.   But no-
thing more than nausea should be caused:
for vomiting  rather rouses than depresses.
(Hunter.)  Nauseating  medicines, em-
ployed after bleeding, has been practised
once  or twice, are often productive  of
considerable  benefit; but there are some
affections, in which they cannot be used,
such as inflammation of the stomach and
intestines.  In  all  superficial inflamma-
tions, however, they may be safely and
advantageously exhibited,  as well as in
most inflammatory affections  internally
situated.  In inflammation  of the dura
mater and brain, and,  indeed, in  every
instance, in which there is an urgent rea-
son for putting as sudden a check as pos-
sible to the continuance of the affection,
the employment  of nauseating doses  of
antimonium tartarizatum, (emetic tartar)
is the one, on which practitioners place
the greatest  reliance, and it is to be pre-
scribed for the purpose of exciting nausea,
as directed below.*

                 Opium.

  The majority  of  surgeons  entertain an
insuperable objection to the administra-
tion of  opiates in almost all  c ases  of  in-
flammation, and the aversion to this prac-
tice is for the  most part deducible from the
recollection of opium being a potent  sti-
mulant.  The plan, however,  has its  ad-
vocates.  (B. Bell, Richter.)   One  of  its
strongest partisans  tells us,  that  opium
particularly lessens  the disturbance of in-
flammation, and it allays pain, which is at
once a principal symptom of the process,
and a cause  of its augmentation, as well
as that of the  fever  Opium also quiets
the inordinate action of the  solids,  the
  • 9r. Antimonii tartarisati  grana duo;
Aquse  distillate uncias quatuor.  Misco
et cola.   Dosis.  Uncia  dimidia  sexta
quaque hora. 
INFLAMMATION.
135
mental' agitation,  and restlessness  so
powerfully, that it well deserves the name
of lie grand antiphlogistic remedy.  It like-
wise occasions a moisture on the surface
of the body, which experience shews is
eminently serviceable in all inflammations
affecting the skin.   When given with this
view, it  :s usually conjoined with anti-
mony, camphor, calomel, or ipecacuanha.
The administration of opium is a gene-
ral practice in all  painful inflammations
arising from external causes,  and it is
attended with perfect  safety when evacua-
tions from the  bowels and bleeding have
been previously  put  in  practice.  Care
must only be taken to give it in sufficient
doses; for small  quantities not only fail
in fulfilling the object, but frequently pro-
duce quite an opposite effect.  During its
employment, the bowels  should be kept
open by  glysters.  The efficacy of opium
chiefly manifests itself in  the early stage
of the affection ;  for,  as soon as the in-
flammatory fever has  extended itself to
the  whole  system,  it loses its beneficial
virtues.  Hence,  in cases  of external in-
juries, it is to  be given the two first days,
immediately after bleeding.  It is to be
given as soon  after the accident as  pos-
sible,  in order to tranquillize the mental
alarm, Jul, if convenient,  towards  the
evening, for the sake of procuring for the
patient a quiet night  (Richter.)  Evacua-
tions being premised,  says the other advo-
cate tor  this medicine, the next object of
importance is to procure ease and quiet-
ness to  the patient,  which, in  cases of
inflammation,  are often of more real  ser-
vice, than any other  circumstance what-
ever.  The most effectual remedy for  this
pu'.pose is opium, which, when the pain
and irritation are  considerable, as very
frequently happens in extensile inflam-
mations, shoutd  never be  omitted.   In
large  wounds, especially  after  amputa-
tions, and other capital  operations,  and
 in punctures of all kinds, large  doses of
opium are always attended with remark-
ably good effects.   In  all such cases,
however, opium, in order to have a pro-
per influence, should be  administered in
very large doses; otherwise, instead of
proving serviceable,  it seems  rather to
have the contrary effect.  This circum-
 stance is, perhaps, the chief reason why
opiates in general have-been very unjustly
condemned in every case of inflammation.
 {B. Bell.)
   On the contrary, they who are averse to
 the use of opium, remark, that, in acute
 inflammation, daily experience shews, in-
 dependently of every theory, that the exhi-
 bition of this medicine increases the ge-
 neral fever,  and  aggravates the local
 action.  Even given  as  a preventive of
inflammation, after operations, anodynes
are almost universally hui tfid, producing
restlessness, heat, thirst, and  afterwards
head-ach, sickness, and frequently, trou-
blesome vomiting.  (Burns.)
  Upon the whole, candour obliges me
to own, that the votes of the majority  of
surgeons in  this  country are decidedly
against the  general use  of opnim  in in-
flammation ; but, after  the performance
of severe operations, and in  all instances,
attended with excessive pain, truth, I be-
lieve,  will justify my saying, that the
voice of most practitioners is in favour  of
the exhibition of this remedy.

          MET ANI) REGIMEN.

  In all cases, the surgeon is to forbid
taking wine and spirits,  and, when the
inflammation is in  the least considerable,
the  same prohibition is  to be made  in
regard to animal food. Watery, cooling,
mucilaginous drinks,  taken  in  a luke-
warm state,  are proper;  for they keep off
thirst  and  heat, and tend to sooth the,
increased action  of  the  whole  arterial
system.  For this purpose,  whey, butter-
milk,  barley-water,   decoction of dried
fruits,  water-gruel, &c. are the best.
  The chamber,   in  which the  patient
lies, should not be kept warmer than his
comfort requires;  for, of all things, heat
keeps up  an increased action in the body,
in the most powerful manner.   For the
same reason, the patient should not  be
covered  with a superfluous quantity  of
bed-clothes.
  The whole body, but  more especially
the inflamed part,  should be preserved  as
free as  possible from every kind of mo-
tion.  Every one knows, that all  motion,
exercise, and muscular exertion,  accele-
rate the circulation, and hence they must
have a pernicious effect on inflammation,
by determining a larger quantity of blood
to the  part affected.

     TOPICAL APPLICATIONS—COLD ONES.

  With the exception of what has been
stated, concerning topical  bleeding,  all
the foregoing remarks relate to the general
treatment of inflammation:  we shall next
consider the local.   A'
   It  has been already   observed,  that
phlegmon is attended with an increase of
heat in the part affected,  and it is an ac-
knowledged and well  known fact,  that the
action of the  arteries, as well as every
other  operation in the animal economy,
is  promoted and increased  by  the  in-
fluence  of  heat.   For  this  reason  an
obvious indication arises, viz. to, reduce
the temperature ofthe inflamed part,by the 
136                           INFLAMMATION
topical application of cold,  and, in parti-
cular, by continually abstracting the heat
generated in the part,  by  keeping up a
constant evaporation from its surface.
  Preparations  of lead, and other  seda-
tive  and astringent substances, are such
as are in the greatest repute for bringing
ab»ut the resolution of inflammation.
  I am decidedly averse to  entering into
minute discussions, concerning the modus
operandi of such medicines  as  are recom-
mended.  These disquisitions would only
extend our  remarks  to an unnecessary
length, and probably fail  in  conveying
satisfactory  information to the  reader.
However, I am firmly of the same senti-
ment with a  preceding systematic writer
(B. Bell) that,  in some circumstances, it
may not  be  improper to deviate so  far
from the general plan, as to render, as  ob-
vious as possible, the propriety of what, at
any  tinw may  be advanced;  for  mere
practical assertions, unsupported by some
foundation  in  reason, can  never  prove
either so useful or agreeable as they might
otherwise be  rendered.
  We have remarked, that the cold  ap-
 Slications, used in the  resolution of in-
 animation, are commonly  such as are of
an astringent and sedative quality. But the
whole class of medicines, which are found
to possess these properties, can never be
recommended  as topical  remedies  for
phlegmonous  inflammation.   Opium   is
one  of the most  powerful of all  seda-
tives; yet,  when  applied to  the surface
of the human body,  (if the cuticle  inter-
vene,) it has little  virtue; and, if  the
part lie excoriated, it is always productive
of some degree of irritation. Hence, how-
ever useful opium may be as  a topical
application to some particular species of
inflammatory affections, which will  be
specified in the course of this  work,  we
may certainly conclude, that it will  never
come  into general  use, as an  external
local application  in  inflammatory cases.
Similar  objections  might,  perhaps,  be
made to  the employment of nearly all se-
dati.es,  in cases  of acute  inflammation
The zincum  vitriolatum, cerussa acetata
(sugar or acetite of fead,) and vinegar, are
the only  medicines of* the astringent and
sedative  class, which seem  to have  ac-
quired permanent celebrity for their effi-
cacy in resolving inflammation
  Extensive experience, and  long estab-
lished trials,  have now  fully   confirmed
the virtue of all those local remedies, in
which the acetite  of lead  is  the active
ingredient.   M. Goulard, and  numerous
other French surgeons, found,  that  the
objections  to the employment  of  many
other sedative  applications in the  treat-
ment of inflammation, did  not  exist
against the use  of the  preparation  of
lead.   The universal  assent of  moderti
practitioners   proves,  indeed,  that the
acetite  of lead, as  a local application
for genuine phlegmonous  inflammation,
is certainly unsurpassed, if not unrivalled,
in point of efficacy.
  Although M.  Goulard, in extolling a
favourite  remedy, has been induced to
assert its  effects to  be more general and
considerable  than  they  properly  will
ever be found  to be;  yet  the world  is
much  indebted  to him; not,  however,
for a new medicine, as every preparation
of lead, recommended by him, was for-
merry, in  some form or other,  known to
every  practitioner; but, for introducing
into more  general use a very  effectual re-
medy for  the discussion of  inflammatory
swellings'. (B. Bell.)
   The preparations  of  lead  certainly
merit the appellation of sedatives.  When
taken internally,  many of the most strik-
ing effects of this mineral are of  a sedative
kind.  The propriety of the term, how-
ever, is more particularly evinced by the
immediate and obvious operation of lead,
when  any of its  preparations are  out-
wardly applied to the surface of an in-
flamed part.  An abatement ofthe differ-
ent symptoms of  pain, and  tension, and
the communication of an agreeable sooth-
ing sensation  to the  part, are  almost al-
ways its direct palpable effects.
  The preparations  of lead are recom-
mended by M. Goulard, as almost equally
applicable to every stage of inflammation.
When swellings  have fully  suppurated,
the employment of, what he calls, the ex-
tractum Saturni, will almost always render
it unnecessary to open them. Even in gan-
grene, the solution of lead is represented
by this zealous writer, as  a remedy, de-
serving the greatest confidence.
  But, notwithstanding,  the  above ex-
aggeration, every man of experience and
observation will allow, that, while there
is a  chance  of accomplishing resolution,
no local applications to phlegmonous in-
flammation, are in general so proper, as
c->ld  lotions,  containing  the acetite of
lead.
  From the poisonous qualities of lead,
when taken into the system, and from the
possibility of this mineral being absorbed
from the surface of the body,  objections
have  arisen against the free  use of its
preparations, even as  outward remedies
in cases of inflammation.  Certain  it is,
however,  that though the  possibility  of
such  absorption  is  proved  by the  oc-
currence of the disorder called  the colica
pictorum, which originates in painters from
the white  lead absorbed  into the system,
yet,  any ill effects from the use of lead, 
INFLAMMATION                           13T
as- an application to inflamed parts, are so
exceedingly rare,  that  they can  hardly
form a serious objection to the  practice.
It is a fact, that,  in inflamed parts, there
is an impediment to  absorption, and this
circumstance  may  tend  to render  the
employment of lead  a  matter  of safety.
Mr. B.  Bell observes, that in all the  ex-
perience he has  had,  of  the  external
application of lead and its preparations,
and in many cases, particularly of burns,
he has known the greatest part of  the
surface of the body covered with them for
days, nay, for weeks together, he does not
rec»llect a single instance of any disagree-
able symptom being ever  produced by
them.
   A lotion composed of cerussa acetata
(sugar of lead), vinegar and water, is one
very commonly employed.*  Occasionally,
bread-crumb  is  moistened in the fluid,
and applied to the part affected, in  the
form of a poultice; but, linen wet in  the
lotion, and kept constantly so, is now al-
most always preferred.  Thus a continual
evaporation is maintained, and  of course
a continual abstraction of heat.
   The aqua lithargyri acetati is preferred
by most .surgeons.
   About a tea-spoonful of this  prepara-
tion, mixed with a pint of water,  makes
a  very  proper lotion  for  all  ordinary
oases.
   When the surgeon is afraid to employ a
solution of lead, he may try one containing
the zincum vitriolatum.  For this purpose
one dram of this  metallic  salt  is to be
dissolved in a pint of  water, and linen
well wet with the lotion, is to be applied
to the inflamed part.
   Many practitioners impute very little
real efficacy either to the acetite of lead,
or sulphate of zinc, contained in the above
applications; and, they attribute all  the
good, that is produced, entirely  to  the
evaporation kept up  from the surface of
the inflamed part,  and to the coldness of
the fluid, in which the metallic salts are
dissolved.   Those, who entertain these
sentiments, think the application of cold
water alone quite as efficacious, as that of
any medicated lotion whatsoever.
   There are particular cases of inflamma-
tion, in which the extravasation of blood
and lymph, into the interstices of the in-
flamed part, is exceedingly copious, while
* $,.   Cerussae Acetata: 33s.
      Solve in Acet.  pur. £iv.
      Et  adde Aq.   Fontanae  distill.
      ibij-
The vinegar  makes the solution more
             complete.
 /Vot. IT.
the swelling is considerable,  and the pain
and  redness not particularly  great.  In
such instances, it is a grand  indication to.
rouse  the action of the absorbents, in
order to remove the extravasated fluid,
and  with this view, a more powerful tlit-
cutient lotion,  than  the  saturnine one,
should  be employed. Sometimes,, it is
better to use embrocations and liniments,
than any sort of lotion.  A very excellent
discutient lotion is  one  of those men-
tioned below.*
  When the part affected  with inflamma-
tion  is  not  very tender,  or when it lies
deep, applications of the vegetable acid
are often had recourse to with consider-
able  advantage;  and the  most effectual
form  of using it seems to be a poultice
made with  vinegar and crumb of bread.
In such cases, it has been thought, that an
alternate use of this  remedy, and the sa-
turnine lotion, has produced more benefi-
cial effects,  than are  commonly observed
from  a continued use of  one of them.
(B. Bell.)  However, surgeons ofthe pre-
sent day seem to think, that vinegar can
be as advantageously applied in the form
of a  lotion,  as in that of a poultice, and,
certainly,  with less trouble
  Alcohol and xtber have acquired some
celebrity,  as local remedies for inflamma-
tion.   Perhaps,  one  great  reason,  why
they are not more extensively used in this
way, is the expence attending such treat-
ment, as these fluids evaporate with great
rapidity  Alcohol may possible prove use-
ful from its  astringent qualities; but, it
seems much more rational to impute both
its virtue, and that of aether, to the power-
ful manner,  in which the  evaporation of
such fluids deprive the inflamed part of its
heat.

WARM APPLICATIONS,  EMOLLIENT TOCLTICES
           AND FOMENTATIONS.

  The absurdity  of  attempting to recon-
cile every useful practice  with a philoso-
phical theory, is, in no  instance, more
strikingly shewn, than  in the opposite
sorts of local  applications, which are of
service in inflammation.   The  generality
of cases undoubtedly receive most relief
* £.  Ammoniac Muriatst 5SS.
     Aceti;
     Spiritus Vini rectificati; sing. ibj.
     M.
  gj.  Aq. Ammon. Acet.
     Spir. Yinirectif.;
    Aq. Distillatae ;  sing. 3"iv. M.
The Aqua  Ammoniac Acet.  alone also
          does very welL 
138
INFLAMMATION.
from the use of cold sedative astringent
lotions; but, there  are  constitutions and
parts,  which derive most service from the
local employment of warm emollient re-
medies.
  Were I to endeavour to  define the par-
ticular instances, in which the latter ap-
plications avail most, I should take upon
me a task, which has baffled all the most
able surgical vvriters.'  The first stage of
the acute ophthalmy, and the hernia hu-
moralis, or inflamed testicle, may be speci-
fied, however, as examples, in which, ge-
nerally speaking,  warm emollient applica-
tions  are  better, than cold  astringent
ones.   If we may judge by the feelings of
certain patients,  there  are  undoubtedly
particular constitutions, in which the lo-
cal use of warm remedies, produces great-
er relief,  than that of cold ones. This cir-
cumstance, however, does not generally
happen;   and,  as  warm  emollient  ap-
plications  of  all kinds have  the most
powerful influence in promoting suppura-
tion, a fact admitted by  every experienced
practitioner, the  use of such  remedies,
while the resolution of inflammation is
practicable,  must  be highly censurable.
But, I am ready to grant, that in all cases
of inflammation, which manifestly cannot
be cured without suppuration, the emolli-
ent plan of treatment ought to be at once
adopted;  for,  the sooner the  matter is
formed, the sooner the inflammation it-
self is  stopped.   The  inflammation at-
tending contused and  gun-shot wounds,
and that accompanying boils and carbun-
cles, are  of this  description.   The in-
flammation,  originating in fevers, com-
monly ends in suppuration, and, perhaps,
it  might  be advantageous, in such in-
stances, also, to  employ at  once  the
emollient treatment.
  Warmth and moisture together, in other
words  fomentations, are commonly had
recourse to in cases of inflammation; but,
when the warmth is as much as the sensi-
tive principle can bear, it  excites action.
Whether it is the action of inflammation,
or the action of the contraction of the ves-
sels, is unknown.  We see that many pa-
tients cannot bear warmth, and, therefore,
it might be supposed to increase the action
of dilatation, and do harm.  But, if the
pain should  arise from the contraction of
the inflamed vessels, benefit would be the
result; though we must  doubt that this
change is produced, as making the vessels
contract would probably give ease. (Hun-
ter.)
  From the preceding   observations, we
must perceive how vain it is to theorize
on this subject, whichever, puzzled  the
genius  and penetration of a  hunter.   In
addition to  what has been already  ob-
served,  I feel totally incapable of gn ing
any useful practical advice,  with respect
to "those cases,  in which warm  emollient
applications should be used in preference
to cold astringent ones.  1 can, however,
with confidence remark, that the surgeon,
who consults the feelings and comfort of
the patient on   this point,  will  seldom.
commit any serious error.  Hence, in all
eases, in which  the first kind of topical
applications seem  not to produce  the
wonted  degree of relief^ let the second
sort be tried.  From  the  opportunity of
comparison, aright judgment may  then
be easily formed.
  The poultice made of  the powder of
linseed is so easily prepared,  th.tt the old
bread and  milk poultice is  now  seldom
made.   As mtich hot water is to be  put
into a basin, as the size ofthe poultice re-
quires, and then the linseed powder is to
be gradually mixed with the water, till the
mass  is of a proper  consistence. Very
frequently, a little sweet oil is also adiicd
to keep the apjHication longer soft  and
moist.
  Fomentations are only to be considered
as temporary applications, while the emol-
lient poultices are  tlie permanent ones.
The former are, at most, never used more
than three times a  day, for the space of
about half  an hour each time.   Two of
the best are directed below.*
  By pursuing the  treatment,  recom-
mended above, the resolution of the in-
flammation will in general begin to  take
place, either in the course of three or four
days, or in a shorter space of time.  At all
events, it  may   usually be known before
the expiration  of  this period, how  the
disorder will terminate. If the heat, pair,
and other attending symptoms abate; and,
especially,  if the tumour begins to de-
crease, without  the occurrence  of  any
gangrenous appearances ; we may then lie
almost certain,  that, by a continuance of
the same plan,  a total resolution will in
time be effected.
  On the other hand, when all the differ-
ent symptoms increase, and,  particularly
when the tumour becomes  larger,  anil
sottish, attended with  a  more violent
throbbing pain, we may conclude, that the
case will proceed to suppuration.  Hence,
an immediate change  of treatment is in-
dicated, and such applications, as were pi o-
* g<.  Lini contusi  Sj.
     Chamaemeli ^ij.
     Aq.  Distill'. ' ILvj.   Paulisper
     coque et cola.
or &. Papaveris albi exsiccati 3'iv.
     Aq.  Purse U.vj.  Coque  usque
     rcmaneuiit Hij.'tt cola. 
LXJ
INT
133
*.cr, while resolution seemed practicable,
are to be left off,  and others  substituted.
This remark relates to the employment of
cold astringent remedies,  which,  wlien
suppuration is inevitable, only do harm,
by retarding what cannot be avoided, and
affording no relief of the pain and  other
symptoms.  If the inflammation, however,
should already be treated with emollients,
no alteration of the topical applications is
requisite,  in consequence of  the  inevita-
bility ofthe formation of matter.   Indeed,
emollient poultices, and fomentations, are
the chief local means both of promoting
suppuration, and  diminishing the pain,
violent throbbing, &c.  which always pre-
cede this termination of phlegmonous in-
flammation.
  But, besides the  substitution of warm
emollient applications for cold astringent
cues, to the  part itself; practitioners have
decided, that it is also prudent, as soon as
the certainty is manifest, to relinquish the
free employment of evacuations,  particu-
larly, blood-letting, and to allow  the  pa-
tient a more generous diet.  When  the
system is too much reduced by the injudi-
cious continuance of the rigorous antiphlo-
gistic treatment, the progress  of the ensu-
ing suppuration is always retarded in a
disadvantageous manner, and the patient
is rendered too weak to support,  either a
long continued, or  a profuse discharge,
which, it may not be possible to avoid.
  On the subject of inflammation, the
best works for perusal are;  Van Swieten's
Commentaries on Boerhaave; Cullen's First
Lines on the Practice of Physic, Vol.  1; John
Hunter on Inflammation, &c; Burns's Dis-
sertations on the same.
  INGUINAL ANEURISMS. See Aneu-
rism.
  INGUINAL HERNIA.  See Hernia.
  INJECTION, (from  injicio, to  cast
into.)  A  fluid, intended to  be  thrown
into a part of the  body by  means of a
syringe.   Thus  port  wine  and  water
form an injection, which is used  by sur-
geons for radically curing the hydrocele,
and, for this purpose, it is introduced into
the cavity ofthe tunica vaginalis, where it
excites  the  degree of inflammation  ne-
cessary to produce  an universal adhesion
between this membrane and the albuginea.
  Thus many fluid remedies are intro-
duced  into  the urethra and vagina  for
curing  the  gonorrhoea.  In  the  article
Gonorrhoea,  will  be  found  an  account
of the  best injections  employed  for  its
relief.  We  here subjoin a few particular
ones not there noticed.
   INJECTIO  ACIOI   MURIATICI.—
9c. Aquae distil, ^iv.   Acid.  Mur.  gutt.
viij. Misce.—Useful when the scalding is
a very troublesome symptom.
  INJECTIO ALUMIXIS.  *. Alum  51.
Aq. pur. §vj.  Misce.—Successfully  em-
ployed by Dr. Cheston, as an injection in
affections of the rectum, either when the
internal coat is simply relaxed,  and dis-
posed to prolapsus,  or when it is studded
with loose fungated  tumours.   In  such
cases, camphor is also  of  service.  The
quantity of* alum may be increased, if the
parts will bear it.
  INJECTIO  CUPRI AMMONIATI.—
£.  Liquoris  Cupri  ammon.  gutt.  xx.
Aquae  rosse  3iv.  Misce.—Strongly  re-
commended by Mr. Foot.
  INJECTIO   QUERCUS—*.  Decocti
quercus  tbj. Aluminis  purificati §ss.
Misce.—Maybe used, when the rectum, or
vagina,  is disposed to a prolapsus  from
relaxation, or in cases of" gleet.
   INTERRUPTED  SUTURES.   See
Sutures.
  INTESTINES WOUNDED.   See  Ab-
domen, Wounds of.
  INTROSUSCEPTION, or Intussuscep-
tion, (from intus, within, and suscipio, to
receive.)  Called also Volvulus.   Is a dis-
ease, produced by the passing of one por-
tion of an intestine into another, and it is
commonly  from the upper passing  into
the lower part.  (J. Hunter.)
  Mr. G. Langstaff has published an inte-
resting paper,  on this subject,  in  the
Edinb. Surg. Journal, No.  XI.; which I
shall take the liberty of freely quoting.
  This gentleman remarks,  that the small
intestines of children are so often affected
with introsusception, in a slight degree^
that most  practitioners  must have had
opportunities of observing the form ofthe
complaint.   The greatest  part of three
hundred  children,  who died either of
worms,  or during  dentition, a the Hos-
pital de la Saltpetriere, and came under
the examination of M.  Louis, had two,
three, four, and even more volvuli, with-
out any inflammation ofthe parts, or any
circumstances leading to a suspicion, that
these affections had  been injurious during
life.  " These cases (says M. Louis) seem
to prove, that introsusception may  be
formed, and destroyed agaiivby the mere
action ofthe intestines." (Mem. del'Acad.
de C/ururg. 4to. torn. 4. p. 222.)  This opi-
nion is confirmed by the authority of Dr.
Baillie, (Morbid Anatomy, 2d edit. p. 162.)
who observes, that^  " in opening bodies,
particularly of* infants, an intussusceptio
is not unfrequently found, which had been
attended with no mischief;  the parts ap-
pear perfectly free from  inflammation,
and they would probably have been easily
disentangled from each other by their na-
tural peristaltic motion."
  The disease, continues  Mr. Langstaff,
assumes  a more dangerous, and,   hjdeed, 
140                         INTROSUSCEPTION.
generally a fatal form, when it occurs at
the termination of the small intestines in
the ccccum. A contracted state ofthe part
to be introsuscepted,  and a dilatation of
that portion of the canal, into which this
part must pass, are essential conditions 10
the formation  of a volvulus; and those
exist no where so completely as in the
situation here alluded to.  The extent, to
which the affection proceeds in this situa-
tion, would appear almost incredible, if it
were  not  proved by  well authenticated
facts.  A person,  who considered the na-
tural situation and connexion ofthe parts,
would of course require the strongest evi-
dence, before he would  believe,  that the
ilium, ccecum, ascending, and transverse
portions of the  colon, may descend into
the sigmoid flexure ofthe latter intestine;
nay more, that they may pass through the
rectum, and be protruded in the form of a
procidentia ani.  Such cases, however, are
recorded.  (Langstaff, in Edinb. Med. and
Surg Journal,  No. XI.)
  This gentleman next relates the case of
a child three .months old, the  body of
which he inspected after death, and found
to confirm the truth of the preceding ac-
count.  The example, was particular in
there being in addition to an extensive in?
trosusception in the usual way, a smaller
invagination in the opposite direction, like
what probably occurred in the case related
by Mr. <Spry;  Med. and Physical Journal,
No. XI  Mr. Home,  in  the Med. and
Chirurg. Trans. Vol. 1. mentions an exam-
ple of  a  retrograde  introsusception, in
which a worm was found coiled up round
the introsuscepted part  The disease took
place in a boy who had swallowed some
arsenic.
  If the following mode of accounting for
introsusception,  be just, it will most fre-
quently  happen  downwards,  although
there is no reason why it  may not take
place in a contrary direction; in  which
case, the chance of a cure will be increased
by the  natural actions  of the intestinal
canal tending to replace  the intestine;
and probably  from this circumstance it
may oftener occur than commonly appears.
(/. Hunter.)
   When the introsusception is downwards,
it may be called progressive,  and when it
happens upwards, retrograde.  The man-
ner in which it may take place is, by one
portion of" a loose intestine being con-
tracted, and the part immediately below
relaxed and dilated;  under which circum-
stances, it might very readily happen by
the contracted portion slipping a little
way into that which  is dilated,  not from
any action in  either portion of  intestine,
but from  some additional  weight  in the
gut above.  How far the peristaltic mo»
tion, by pushing  the contents on  to the
contracted parts,  may  force  these  into
the relaxed, Mr.  Hunter will  not  deter-
mine, but is inclined to suppose that it
will not.  (J. Hunter)
  By this mode of accounting for an acci-
dental introsusception, it may take place
either upwards or  downwards; but if a
continuance or an increase  of it arises
from the action of the intestines, it must
be when it is downwards, as we actually
find to be the case; yet this does not ex-
plain those  in which a considerable  por-
tion of  intestine  appears  to  have been
carried into the gut below : to understand
these, we must  consider the  different
parts which form the introsusception.  It
is made up of three folds of intestine ; the
inner, which passes down, and being re-
flected upwards,  forms the second or in-
verted portion, which being reflected down
again, makes the third or containing part,
that is the outermost, which is always in
the natural position.  (J Hunter.)
  The outward fold is the only one which
is active,  the inverted portion being per-
fectly passive, and squeezed down by the
outer, which inverts more of itself, so that
the angle of inversion in this case is always
at the angle of reflection of the outer into
the  middle portion or  inverted  one,
while the innermost is drawn in.  From
this we  can readily see how an introsus-
ception, once begun, may have any length
of gut drawn in.  (J. Hunter.)
  The external portion  acting upon the
other folds in the same way as upon any
extraneous  matter, will by its peristaltic
motion  urge them  further; and, if any
extraneous  substance is detained  in the
cavity of the inner portion, that part will
become a fixed point for the outer or con-
taining  intestine to  act upon.  Thus it
will be squeezed on, till at last the mesen-
tery preventing more ofthe innermost part
from being drawn  in, will act as a kind
of stay, yet  without entirely hindering the
inverted outer fold  from going «till fur-
ther. For it being the middle fold that is
acted upon by the outer, and  this action
continuing after the inner portion becomes
fixed, the gut is thrown into  folds upon
itself; so that a foot in length of intestine
shall form an introsusception not more
than three inches long.  (/. Hunter.)
  The outer portion  of intestine is alone
active in  augmenting the disease when
once begun; but  if  the inner one  were
capable of equal action  in its natural di-
rection, the effect would be the same, that
of  endeavouring to invert  itself, as in a
prolapsus ani; the outer and inner por-
tions, by  their action, would tend to draw 
INTROSUSCEPTION.
i<U
in more of tlie gut, while the intermediate
part only would, by its action, have a con-
trary tendency.  (/. Hunter.)
  The action of  the abdominal muscles
cannot assist in either forming, or continu-
ing this disease, as it  must  compress
equally  both above and  below,  although
it is capable of producing the  prolapsus
ani.   (J Hunter.)
  When an introsusception begins at the
valve ofthe colon, and Inverts that intes-
tine,  we find the  ilium  is not at all af-
fected ;  which proves that the mesentery,
by acting as a stay, prevents its inversion.
if. Hunter.)
  From the natural  attachment of the
 mesentery to the intestines, one would, at
 the first view of the subject, conceive  it
 impossible for any one portion of gut to
 get far within  another;  as the greater
 extent of mesentery that is carried in along
 with it would render its further entrance
 more and  more difficult, and we should
 expect this difficulty to be greater in the
 Large intestines  than in the  small, as be-
 ing more closely confined to their  situa-
 tion ; yet one of the largest introsuscep-
  tions of any known  was in  the colon,
  as related by Mr. Whateley.  (Vid. Phil.
  Tram. Vol 76. p. 305.)
  . The introsusception  appeared to  have
  begun  at the insertion of the  ilium into
  the colon, and to have carried in the cce-
  cum with its appendix.  The ilium passed
  on into tiie colon, till the whole of the as-
  cending colon, the transverse arch, and
  descending colon, were  carried into the
  sigmoid flexure and rectum..  The  valve
  of the  colon being the leading part, it at
  last got as low as the anus;  and when the
  person went to stool he only emptied the
  ilium, for one half of the large intestines
  being  filled  up by the  other, the  ilium
  alone,  which passed through the centre,
  discharged its  Contents.  (/. Hunter.)
    Two questions of considerable import-
  ance  present themselves to  the  mind
  in considering this   subject ;  whether
  there  are any symptoms, by which tlie ex-
  istence ofthe affection can be ascertained
  during life ?  And whether we possess any
  means of relieving it,  supposing, that its
  existence could be discovered ? The symp-
  toms  attending an  introsusception,   are
  common to inflammation ofthe intestines,
  hernia, and obstruction of the canal, from
  whatever  cause,  and a volvulus  is  the
  least  frequent  cause  of such symptoms.
  (iMugstaff.)  In the   case, published by
  this gentleman, and  in those related by
  Mr. Hunter and Mr  Spry,  the seat of the
  disease was clearly  denoted by  a hard
  tumour on the left side of the abdomen.
  This  circumstance, together with the un-
  p-is.-ibilitv of throwing "P mare  than a
very small quantity of fluid in clysters,
(Hevin, Spry, Langstaff;) and tlie pi esence
of the other symptoms,  would lead us to
suspect the nature of  the disorder.   If
the invaginated portion  descended so low
as to protrude through  the anus,  and  we
could ascertain, that it  was not an inver-
sion of the  gut, the cause might be con-
sidered as clear,  and we should  have no
hesitation   in  delivering  a   prognosis,
which, by preparing the friends for  the
fatal  termination,  would exonerate  us
from all blame on its occurrence.  (Lang-
staff)
   In the treatment of this disease, bleed-
ing, to lessen the inflammation that might
be brought on, and quicksilver to remove
the cause have been recommended.
   Quicksilver  would   have little  effect
either in one way or the other, if the in-
 trosusception were downward; for it is to
 be supposed that it would easily  make its
 way through  the innermost contained
 gut, and,  if it should  be stopped in its
 passage, it would, by increasing its size,
 become a cause (as before observed) of
 assisting the disease.   In cases of the re-
 trograde kind, quicksilver, assisted by the
 peristaltic  motion, might be expected to
 press the introsusception back;  but even
 under such circumstances it  might get
 between the containing and  inverted gut
 into the angle of reflection, and,  by push-
 ing it further on, increase the. disease it
 is intended to cure..  (/. Hunter.)
    Every thing that can increase^ the ac-
 tion of the intestine downwards  is to be
 particularly  avoided,  as tending to in-
 crease the peristaltic motion of  the outer
 containing gut, and thus to continue the
 disease.   Medicines can never  come in
 contact with the outer fold, and, having
 passed  the inner, can only  act on  the
 outer below, therefore cannot immediately
 affect that portion ofthe outer which con-
 tains the  introsusception; but  we must
 suppose that whatever affects, or comes
 in contact with the larger portion ofthe
 canal, so as  to throw  it into action,  will
 also  affect by  sympathy any  part  that
 may escape such application.  Mr.  Hun-
 ter therefore advises giving vomits,  with
  a view to invert the peristaltic motion of
  the containing gut, which will have a ten-
  dency to bring the intestines  into  their
  natural situation.
    If this practice should not  succeed, it
  might be proper to consider it as  a re-
  trograde  introsusception, and  by admi-
  nistering  purges endeavour to increase
  the  peristaltic motion  downwards. (J.
  Hunter.)
     I cannot agree with Mr. Langstaff, that
  it is to be regretted, Hunter's name should
  be affiled to the preceding proposal, or 
142              IN V
1RI
that it is an absurd one; for purgatives
y,nd emetics were only  recommended  to
increase the peristaltic action, the former
downward, the latter upward, according
as the supposed nature of the case might
require,  and this effect they  certainly
would have, notwithstanding vomiting is
an early and  constant  symptom of the
disease, and an insuperable constipation
an  equally invariable   attendant.  The
method,  I  allow, however,  is  not  very
hopeful,  on account of the  existence of
adhesions.   Mr. Langstaff remarks, that
the Recherclies Historiques sur la Gastroto-
nde dans le cos de  Volvulus, par M. Hevin,
(Mem. del'Acad, de Chirurgie, Tom 4, 4to.)
contain many interesting facts and much
sound reasoning.  There we find a  very
ample discussion of the question, concern-
ing the propriety of opening  the abdo-
men,  in  order to disentangle  the intro-
suscepted  intestine;  a proposal which
M Hevin condemns.
   If the  equivocal and uncertain nature
of the symptoms  of volvulus,  were not
sufficient  to deter us  from undertaking
an operation, which, under  the most fa-
vourable circumstances, could  not fail to
be extremely difficult, and imminently
hazardous to the  patient, the state of the
invaginated parts will  entirely banish all
thoughts of such an imprudent attempt.
 The different folds  of the  intestine  be-
come agglutinated to each other, so  that
they can hardly be withdrawn after death;
(Simpson, Edinburgh Med. Essays, Vol. 6.
/levin's 4th Obs.  Malcolm,  Physical and
 Lit. Essays, Vol. 2, p. 360   Hunter,  Med.
and Cidr. Trans, and Soemmering in Trans.
of BuiUie's Morb. Anat.) the stricture on
the introsuscepted part, causes  it to in-
flame, and even  mortify.   (Soemmering.)
It is very clear, that, in this state of parts,
the  operation of gastrotomy  would be
totally inadmissible, even  if the symp-
toms could clearly indicate the nature of
the case, and  the affected part could be
easily reached and examined. (Langstaff,
in Edinburgh Medical and Surgical Jour-
 nal.)
   The forcible injection of clysters was
found useless  by Dr.  Monro, and  the
agglutination of the parts  must  produce
 an insuperable obstacle to the bowels be-
 ing pushed back  by this means.  (Lang-
 staff.)  Some have proposed the employ-
 ment of a long bougie, or a piece of whale-
 bone, to  push back  the  intestine;  and
 this  proposal may be adopted, when we
 are furnished with an instrument, adapted
 to follow the windings of the large intes-
tine to its origin in the right ilium,  with-
 out any risk of perforating the gut  in its
 course.  (Langstaff.)
   We most confess,  both surgery and
medicine are almost totally  unavailing -n
the present disease.   Yet  here,  as in
many other instances,  the resources of
nature are exhibited in a most wonderful
and astonishing manner, while  those of
art  completely fail.   The  invaginated
portion  of intestine sometimes  sloughs,
and is discharged per anum,  while the ag-
glutination  of  the  parts preserves  the
continuity  of the intestinal canal.   The
annals of medicine furnish numerous in-
stances, in which long pieces of gut have
been discharged in this manner, and the
patient  has  recovered.   Hence,  some
hope may be allowed under the  most un-
promising circumstances  In a  case, re-
lated in Duncan's Commentaries, eighteen
inches of small intestines were voided per
anum, Vol.  9,  p. 278.   Three similar in-
stances  occur  in M.  Hevin's  Memoir;
twenty-three inches of colon came away
in one of these, and twenty-eight of small
intestines in another.   Other cases occur
in the   Physical and   Literary  Essays,
Vol.  2, p. 361; in  Duncan's  Essays,
Vol. 6,  p.  298; in  the Medical and Chi-
rurgical Transactions,  Vol. 2; where Dr.
Baillie  states,  that  a yard of intestine
was  voided.  The/patients did not, how-
ever, ultimately  survive in every one of
these instances.   (Langstaff, in  Edinb.
Med and Surgical Journal.)
   For  information  concerning  intussus-
ceptio,   I  would particularly  refer  the
reader  to M. Hevin, in Mem. de I'Acad, de
 Chir.   Hunter's Observations, in the Medi-
cal and Chirurgical Transactions.  L'En-
cyclopedic Methodique,Partie Chirurgicale;
Art.  Gastrotomie.  And Langstaff's Re-
marks in the Edinburgh Med. and Surgical
Journal, No. II.
   INVERSION  OF  THE  UTERUS.
See Uterus, Inversion of.
   IRIS, PROLAPSUS OF.  As long-as
the humours, which fill the cavity of the
eye,  and in which the iris  is immersed
and suspended,  remain in perfect equili-
brium  with respect  to each other,  that
 membrane retains  its  natural position,
and a  suitable distance from the cornea.
 While  such an equilibrium continues, the
 iris,  although of  a  very delicate and
yielding texture, contracts, and relaxes
itself, without ever forming any irregular
fold.  But,  when  the aqueous humour
has  escaped through an accidental, or ar-
 tificial  opening in the cornea, the iris is
pressed forward  by the humours situated
 behind it; and is urged gradually towards
 the  cornea, until a portion of it  protrudes
from the eye, at the same opening, through'
 which  the aqueous  humour made its es-
cape.   Thus  a small tumour of the same
colour  as  the iris forms on the  cornea,
and is named, by the majority of surgeons, 
IRIS.                                 143
staphyloma of the iris; but, for the sake
of distinguishing the disease more parti-
cularly from another, to which the term,
staphyloma is more properly applicable,
Scarpa prefers  calling  it "with  Galen,
procidentia, or prolfsus of the iris.
  The causes of this complaint are such
wounds and ulcers  of the comea, as make
an 0|>emng of a certain extent into the
anterior chamber of the  aqueous humour,
and  such  violent contusions  of the eye-
ball, as occasion a  rupture of the cornea.
If the edges of a wound in this situation,
whether accidental, made for the purpose
of extracting the cataract, or evacuating
the matter  of an  hypopium (as is the
practice of some), be not  brought imme-
diately  afterwards into reciprocal con-
tact, or continue, not sufficiently aggluti-
nated together to  prevent  the escape  of
the aqueous humour  from  the anterior
chamber, regularly as this fluid is repro-
duced ;  the iris, drawn by its continual
flux towards the cornea, glides between
the lips of the wound, becomes elongated,
and a portion of it gradually protrudes,
beyond the cornea, in the form of a small
tumour.   The  same thing  takes place,
whenever the eye-ball  unfortunately re-
ceives a blow, or is too much compressed
by bandages, during the  existence of a
 recent wound ofthe cornea.  Also, if the
patient should be affected, in this circum-
 stance,  with a spasm of the muscles  of
 the eye, with violent and repeated vomit-
 ing, or with strong and frequent cough-
 ing, a prolapsus of the iris may be caused.
 When an ulcer of the cornea penetrates
 the anterior chamber  of  the aqueous
 humour, the same inconvenience happens
 more frequently, than when there is a re-
 cent wound of that membrane;  for, the
 solution of continuity in the cornea, wis-
 ing from an ulcer, is attended with loss of
 substance, and in  a membrane so tense,
 and compact, as this is, the edges of  an
 ulcer do not admit of being brought into
 mutual contact.
   The little tumour  is likewise  necessa-
 rily of  the same colour as the iris, viz.
 brown, or  greyish, being surrounded  at
 its base  by an  opaque circle of  the cor-
 nea, on  which membrane there is an  ul-
 cer, or a wound of not a very recent de-
 r>cription.
   As it usually happens, that the cornea
 is only penetrated at one  part of its  cir-
 cumference by a  wound, or ulcer, so in
 practice we commonly meet with only one
 prolapsus of  the  iris  in  the  same eye.
 tyut, if  tha cornea should happen to  be
 wounded, or ulcerated, at several distinct
 points, the iris may protrude at several
 different places of the same  eye, forming
 an equal number of  small projecting  tu-
mours on the surface of tlie cornea. Scar-
pa has seen a patient, who had three very
distinct protrusions of the iris on the same
cornea, in consequence of three separate
ulcers, penetrating  the  anterior cham-
ber of the aqueous humour; one in  the
upper, and two in  the lower segment of
the cornea.
  If we  reflect  a little on the delicate
structure of the  iris; the great quantity
of blood-vessels which enter it, ;.nd the
numerous nervous filaments,  which pro-
ceed to be distributed to it, as a common .
centre;  we shall easily conceive the na-
ture,  and severity of those   symptoms,
which are wont to attend this disease,
how small soever tiie portion  of the iris •
projecting from  the cornea may be, even
if no larger than  a  fly's head.  The hard
and continual  frictions, to which  this
delicate  membrane  is then exposed, in
consequence of the motions ofthe eyelids;
together with the access of air, tears and
gum to  it, are causes  quite adequate to
the production  of continual  irritation;
and the  blood,  which tends to the point
of  the greatest  irritation, cannot iiiil to
render the projecting portion  of the iris
much larger, almost directly after its pro-
trusion, than it was at the moment of its
first passing through the cornea.  Hence,
it becomes, soon after the prolapsus, more
incarcerated and irritated, than it was at
first.  In the incipient state of the com-
plaint, the patient  complains  of a pain,
similar to what would arise from a. pin
penetrating the  eye ; next he begins to
experience, at the same time,  an oppres-
sive sensation of a tightness,  or constric-
tion,  over the whole eye-ball.  Inflamma-
tion of the conjunctiva,  and  eyelids,  a
burning effusion of tears, and an absolute
inability to endure the light, successively
take place.  As the protruded portion of
the iris drags after  it all the rest of this
membrane, the pupil assumes of mechani-
cal necessity of an oval shape, and deviates
from the centre of the iris, towards the
seat of the  prolapsus.   The intensity of
the pain, produced by the inflammation,
and  other symptoms, attendant  on the
prolapsus of the iris, does not,' however,
always continue to increase.
   Indeed, in practice, cases of old protru-
sions of the iris often occur, where, after
the disease has been left to itself, the pain
and inflammation spontaneously subside,
 and the tumour of the iris becomes almost
 completely  insensible.  Scarpa mentions
 his having seen a man, fifty years of age,
who  had had a prolapsus ofthe iris in the
 right eye ten  weeks; it was as large as
 two  grains  of millet  seed;   the patient
 bore it with the greatest indifference, and
 without any other inconvenience, than  a 
144
IRIS.
little chronic redness of the conjunctiva,
and  a difficulty  of moving  the  eye-ball
freelv, hi consequence  of the friction of
the lower eyelid against the tumour formed
bv tie  ;ris.  When the extremity of the
finger was  applied,  the little  tumour
seemed hard and callous to the touch.
  This  phenomenon was partly owing to
the  constriction, which the base of the
tumour of the iris  suffered  between the
lips  of the wound, or ulcer of the cornea.
The protruded portion of the iris loses its
natural  exquisite sensibility,  in conse-
quence of such compression, or strangu-
lation.  The phenomenon was also partly
ascribable to the iris being deprived of its
vitality  by the induration, and callosity,
which were occasioned by the long expo-
sure  of this membrane to the air,  and
tears.
  In the early stage of this disease, some
direct the iris to be replaced in its proper
situation by means of a whalebone-probe ;
and, in case of difficulty, to make  a dilata-
tion of the wound, or ulcer, of the cornea,
by an incision, proportioned to  the  exi-
gency of the case, as we are accustomed
to do, in order to return a  strangulated
intestinal hernia.   Others  only  recom-
mend strangulating the  prolapsed portion
of the iris, with  a view of making it con-
tract and shrink into the  eye;  or sud-
denly exposing the eye  affected to a very
vivid light,  in the belief, that, as the pu-
pil then forcibly  contracts,  the  piece of
the  iris, engaged between the lips of the
wound,  or  ulcer of the cornea, will  rise
to its  proper place.  However,  Scarpa
strongly contends that  all such methods
are absolutely useless, and even danger-
ous.  Supposing  it were possible, by such
attempts, to reduce the iris to its proper
situation, without  tearing, or injuring  it
in any manner whatever, still tiie aqueous
humour would escape as  before,  through
the'  wound, or uicer of the cornea, so that
the  iris, when replaced, w ould fall down,
the  moment afterwards, and project from
the  cornea,  in the same way as before the
operation.
   It cannot be denied, that the prolapsus
of the iris is  an afflicting accident: but,
when it is remembered, that surgery has
no means of suppi essmg at once, or, at
least, of suspending  the escape of  the
aqueous humour  through a wound,  much
less through an ulcer of the cornea, when
either exceeds certain limits, the prolap-
sus of the iris, far  from being an evil in
such unfavourable circumstances, will be
found rather useful,  and, perhaps,  the
only means of preventing the  total loss of
the  oigan of sight; for, the flap of the
iris  insinuates itself, like a plug, between
the edges of the  wound, or ulcer ofthe
cornea, and thus completely prevents tlie
exit of tiie aqueous humour.
  In  consequence  of this  fluid  being
quickly regenerated, and unable to escape
any  longer  through the cornea ;  it pre-
vents the further  protrusion  of the iris,
removes the rest of this membrane  to a
greater distance from the cornea, and, by
re-establishing the equilibrium between
it and the humours of the eye, resists the
total loss of sight.  If this be evident of
itself, it  is 'equally  obvious, that every
known method, adapted to replace the
prolapsus of the iris, must be useless, or
dangerous.
  In  conformity to such principles, there
are two principal indications for the sur-
geon to accomplish,  in the treatment of
the recent prolapsus ofthe  iris.  The first
is, to  diminish,  as speedily as possible,
the excess of exquisite  sensibility in the
protruded part of the  iris;  the other is
gradually to destroy  the projecting por-
tion of this membrane,  to  such a depth,
as. shall be sufficient to  prevent the httlp
tumour from keeping  the edges of the
wound, or ulcer of the cornea, too much
asunder,  and, at length,  retarding  the
cicatrization.   The  adhesion,  however,
which connects the iris with the inside of
the cornea, must not be destroyed.
  To  fulfil these indications, nothing is
more  effectual than touching the portion
of the iris  projecting from  the cornea,
with the oxygenated muriate of antimony
(butter of antimony), or with what is more
expeditious and convenient, the argentum
nitratum,*so as to form an eschar of such
a depth as occasion  may  require.  That
this operation may be effected with quick-
ness and precision, it is necessary that an
assistant, standing behind the patient's
head, should support  the upper eyelid
with Peltier's elevator;  and that the pa-
tient, if endued with reason, should keep
his eye steadily fixed on one object.
  While the assistant  gently  raises the
upper  eyelid, the surgeon must depress
the lower one, With the index and middle
fingers of his left hand; while, with the
right, he is to be ready to touch the little
prominence formed by the iris, with the
argentum  nitratum,  scraped to a point
like a crayon. This  is  to be  applied to
the centre of the  little tumour,  until an
eschar of sufficient depth is formed. The
pain which the patient experiences at this
moment, is very acute;  but,  it subsides
as soon as the eye is bathed with warm
milk.   The  caustic,  in  destroying the
projecting portion  of the iris, destroys
the principal organ of sensibility, bv co-
vering it with  an eschar, of  sufficient
depth to protect the part affected from the
effecjt of the  friction of tlie eyelids,  and 
IRIS.                                 H>
from ooming into contact with the air and
tears. This is the precise reason, not only
why the sense of pricking and constric-
tion in tiie eye, of which such patients
complain so  much, abates after  the  ap-
plication of the caustic, but also why  the
inflammation  of the conjunctiva under-
goes a considerable diminution, as well
as th* burning  and copious effusion of
tears.
  As in the ease of ulcer of  the cornea,
these advantages only last while the eschar
remains adherent  to   the  little tumour
formed by the iris;  when  it falls off, as
it usually  does two or three days  after
the use of the caustic,  all the above-men-
tioned symptoms are rekindled, with this
difference, that they are less intense and
acute, than they  were previously, and  the
tumour of the iris is not so prominent as
it was before the caustic was applied.
When  these  symptoms make  their  ap-
pearance, the  surgeon   must once  more
have recourse  to the argentum nitratum,
with the  precautions  explained  above;
and he is to employ it a third, and even a
fourth time, as occasion may require,  un-
til  the prominent portion  of the iris is
sufficiently reduced to a level with  the
edges of the wound, or ulcer of the cor-
nea, and no obstacle to the  granulating
process, and complete  cicatrization con-
tinues.
  There is a certain period, (as was stated
in the article, Cornea,  Ulcers of)  beyond
which the  application  ot  caustic to  the
protruded iris, becomes exceedingly dan-
gerous, though at  first ft may have been
highly beneficial; beyond  which,  the es-
char, which previously  soothed the pain,
exasperates it, and re-produces the  in-
flammation of the conjunctiva  in almost
as vehement a degree as in the beginning
of the disease.   This appears to  Scarpa
to be the case, whenever the surgeon con-
tinues  to  employ  the  caustic, after  the
little tumour ofthe iris  has been destroyed
to a level with the external edges of  tlie
wound, or ulcer of the cornea, and  the
application begins to destroy the granu-
lations just  as  they   are   originating.
Hence, in the treatment of this disease,
as soou as the surgeon  perceives, that  the
part of the iris, projecting from the cor-
nea, is sufficiently  lowered, and that  the
application of the  argentum  nitratum,
far  from allaying,  only irritates the dis-
ease, he  must desist entirely from  using
the caustic, and be content with introduc-
ing  between  the eye  and eyelids,  every
two hours, a  vitriolic collyrium with  the
mucilage  of quince-seeds,  or  one  com-
posed of the  sulphate  of  zinc and  white
of egg.  He  is  to employ,  successively
every morning and evening,  Janin's ophf
    Vol,  II.
thalmic ointment, qualified with a dou-
ble, or triple proportion of lard.  If the
stimulus of such  local remedies should
not disturb the work of nature, the ulcer
is constantly seen to diminish gradually in
size, and, in the course of a fortnight, to
become covered with a cicatrix.
  The adhesion, which the projecting part
of the iris contracts to  the internal mar-
gin of the wound, or ulcer of the cornea,
during the treatment,  continues the same
after the perfection of the external  cica-
trix, and of course during the rest of the
patient's life.   Hence,   even   after  the
most successful treatment of the prolapsus
of the iris, the pupil remains  a little in-
clined towards  the place of the cicatrix
in the cornea, and of an oval figure.   The
change in the situation and shape  of the
pupil causes, however,  little or  no dimi-
nution of the patient's faculty of discern-
ing distinctly the smallest objects; and
is much less detrimental to 'the sight,
than one,  inexperienced in these matters
might conceive; provided the scar on the
cornea be not tooextensive, aor situated
exactly in the centre of this membrane.
In the first case, the sight is the less ob-
structed, as the pupil, which, on the first
occurrence of the prolapsus, was narrow,
oblong,  and drawn considerably towards
the wound, or ulcer, gradually  enlarges,
and  forms a less contracted oval.  As
soon as the wound is  completely healed,
the pupil tends, in some degree,  to oc-
cupy its former situation in the centre of
the cornea.   Richter  has, also, noticed
this fact.
  The mode of treating  the prolapsus of
the iris  here explained, is what Scarpa
has found to  be the safest,  and  most ef-
fectual of all  other  methods, that  have
hitherto  been  proposed ; not excepting
that of removing the little tumour, formed
by the iris on the surface of the cornea,
by a stroke of the scissars.
  Certainly, if tiie success of such a reci-
sion were "to correspond, in  all  cases,
with the promises, which some surgeons
have made, nothing would contribute in a
greater degree to exjiedite the cure of the
prolapsus of  the  iris.   But, experience
lias informed Scarpa, that  this recision
can only be practised with a hope of suc-
cess, when the iris has contracted a  firm
adhesion to the internal edge of the, wound,
or ulcer of the  cornea;  and, more espe-
cially in that ancient  prolapsus of the
iris, in which the projecting portion ofthe
iris has become with time almost insensi-
ble, hard,  and callous, w th its base stran-
gulated between the edges of the wound,
or ulcer of the. cornea,  and besides being
adherent to ihem, having also the shape
of a slender pedicle.   Scarpa adds, he
    T 
146                                  IRIS.
   has seen an incarcerated  one fall off of
   itself.
      In such circumstances,  the recision of
   the old prolapsus ofthe iris is not attend-
   ed with  the  least danger; for,  after re-
   moving with a stroke of the scissars, that
   prominent  portion of the iris, which has
   already contracted internal  adhesions to
   the ulcerated margin of the f.ornea, so as
   to reduce it to  a level with  the external
   edges  of the ulcer, there is no hazard of
   renewing the effusion of the  aqueous hu-
   mour,  or giving an opportunity for an-
   other  piece of the iris to be protruded.
   One, or two applications of "the argentum
   nitratum suffice afterwards for the pro-
   duction  of granulations on the  ulcer of
   the cornea, and the formation of a cica-
   trix.   But, it is not so, in the treatment
   of the recent prolapsus of the iris, which
   has no adhesions to the internal edges of
   the wound, or ulcer of the cornea.
      In four subjects recently  affected with
   prolapsus  of the iris, after  Scarpa  had
   removed,  with a pair of convex-edged
   scissars, a portion of that membrane pro-
   jecting beyond the cornea,  of" about the
   size ofa fly's head, it was with regret that
   he found on the ensuing day, that a new
   portion of the iris, not less than the first,
   had made its  way through the ulcer of
   the cornea, and that the pupil  Was very
--> much  contracted, and drawn considerably
   further towards the ulcer of the cornea.
   These circumstances took place, notwith-
   standing  he touched  the won rid imme-
   diately afterwards with the  argentum ni-
   tratum, as well as the edges of the ulcer
   ofthe  cornea.  He has therefore cause to
   fear, should  he ever have occasion to di-
   vide such  a  little tumour again, that it
   would reappear, and always with an ad-
   ditional protrusion of the iris, and a fur-
   ther distortion of the pupil.  Hence, the
   first lesson has made him content to treat
   the disease with caustic, in  the manner
   explained  above; and all the  four sub-
   jects in question were successfully cured,
   > excepting  that their pupils, in conse-
   quence of being drawn too much towards
   tlie situation of the  ulcer of the cornea,
   were  more covered than they ought to
   have been, by the cicatrix.
      Before concluding this article, we beg
   the  attention of surgeons, to a particular
   species of prolapsus, much less frequent,
   indeed,  than that of the iris; but,  which
   does occur in  practice, and, in Scarpa's
   opinion, is very  improperly  termed by-
    mode.]! oculists, " prolapsus ofthe tunic of
    the aqueous humour." (Junin, Pellier, Gue-
    rin, Glci-e, £Jc.)
      This disease consists of  a transparent
   vesicle,  tilled with an  aqueous fluid, and
    composed of a very delicate membrane,
which  projects from the wound, or ulcer
of the  cornea, much in the same  way as
the iris does under similar circumstances.
Scarpa has several times seen this trans-
parent vesicle  full of water, elongating
itself beyond the cornea,  shortly after
the  operation for the  extraction of the
cataract, and sometimes,  also, in conse-
quence of an ulcer of the  cornea, espe-
cially after rescinding a prolapsed  portion
of" the/iris.
  Oculists are, for the most part, of opi-
nion, that this little transparent tumour
consists  of the delicate, elastic, diapha-
nous membrane,  which invests  the inner
surface of the cornea, and is described by
Descemet and Demours.   "  As soon as
the  membrane lining the  cornea (they
say) is exposed by the wound, or ulcer of
the  latter, and the  delicate  pellicle can
no longer resist  the impulse  of the  hu-
mours pressing  behind it, it is necessi-
tated to  yield gradually, to become elon-
gated, and to project from the wound, op-
ulcer of the  cornea, exactly in  the form
of a pellucid vesicle."  But, how remote
this theory is from  the truth,  must be      .
manifest to every one, who reflects at all
on the following circumstances:  1. The
delicate and elastic pellicle, described by
Descemet and  Demours, is not  separable  **
by any artifice from the inner surface of
the  corhea, except near where the cornea
and sclerotica unite.  Since these pro-
truded vesicles make their appearance in
practice  at every  point of the cornea, and
even at its very centre, where the above
pellicle is certainly neither separable, nor
distinct from the  compact texture of the      j
cornea;  it may at least  be asserted, that
the  tunic or the aqueous humour  does
not, in   every instance,  constitute  the      |
transparent  vesicle  in  question.  2. It is
a well known fact,  that  this  vesicular,      \
pellucid  prolapsus   happens more  fre-
quently  after the extraction  of the cata-
ract, than on any other occasion.  In this
case, since the tunic of the aqueous hu-
mour has certainly been divided to afford
an  exit to the crystalline, no one-can be
of opinion, that  the  transparent  vesicle,      ,
which protrudes from the  come?  after      '
this operation, ought  to be attr"' .ted to      i
the  distention and protrusion of the tunic
of the aqueous humour.  3.  If, in cases
of ulcers of the cornea,  the t transparent
vesicle should sometimes appear after the   (•  i
recision  of the prolapsus of the iris, it is    ,
obvious,  that if  it consisted of the tunic
of the aqueous humour, it ought invaria-     i
bly  to appear before the prolapsus of the     J
iris. 4.  Should the surgeon remove the
protruded vesicle to a level with the cor-
nea by a stroke of the scissars,  a small
quantity of limpid  water is seen to ooze
_r 
IRIS.                                 147
out, at the moment when the incision is
made, without any part of the  aqueous
humour escaping from the anterior cham-
ber.   This inconvenience would be in-
evitable',  were the protruded  vesicle in
question  formed by  the delicate elastic
pellicle,  which is said to invest the inner
surface of the cornea.  Besides, the little
transparent tumour disappears when the
incision is made ; but  oftentimes another
one, exactly similar to what was cut off,
is  found in the very  same place on the
following day.  Had the little transparent
tumour been composed of the tunic of the
aqueous  humour, elongated out  of  the
wound,  or ulcer of the cornea,  it could
not at all events have been reproduced at
the same part of the cornea.
  Actuated by such reflections, it is clear
to Scarpa,  that the pretended  prolapsus,
of the tunic  of the aqueous humour, is
not what  it  is  imagined  to be; but,
strictly  speaking,  nothing more  than  a
forcible protrusion of  a portion of the vi-
treous humour, which, from  too much
pressure  being made on the eye, either at
the time of the operation, or afterwards,
or from a spasm of the muscles of the eye,
insinuates itself between the edges of* the
wound after  the extraction of the cata-
ract, and projects in the form of a trans-
 arent vesicle.   The  same thing  also
 appens after ulcers of the cornea, when-
ever the aqueous  humour has. escaped,
and a portion of the  vitreous  humour is
urged by forcible pressure towards  the
ulcer  facing the pupil; or whenever an
elongated piece of the vitreous humour,
after the recision of  a prolapsed portion
ofthe iris, passes by a shorter route, than
through  the  pupil, between the  lips of
the ulcer of the cornea.  At  length, we
understand, why in both these instances a
transparent vesicle forms,  even after the
recision of the  tunic of the aqueous hu-
mour, or ulceration of  the cornea;  and
why it very often reapjsears in the same
place, though it has been cut  away to a
level  with the cornea.  It is because one
or more cells  of  the vitreous humour,
constituting the transparent vesicle, are
succeeded  after their removal by other
cells ofthe same humour, which glide be-
tween the lips of the  wound,  or ulcer of
the cornea, into the situation of the re-
ceding ones.
  The treatment of this species of pro-
lapsus consists in removing the transpar-
ent vesicle, projecting from the wound,
or ulcer, by  means of  a cutting instru-
ment, and  bringing  the  edges  of  the
wound of tha  cornea immediately after-
wards into  perfect apposition,  in order
that they may  unite together as exactly
as possible.   But,  when there  is an ulcer
ofthe cornea, as soon as the vesicle is re-
moved,  the sore must be touched with
the argentum nitratum, so that the eschar
may resist  any  new prolapsus  of" the vi-
treous humour, and at the same time dis-
pose the ulcer of the cornea  to granalate
and heal.
  In this kind of prolapsus,  what pro-
trudes through the cornea is only a subtile
little membrane, tilled with water, and
quite destitute of sensibility    Its detach-
ment from  the rest of the eye,  is a matter
of trivial importance; while, on the con-
trary, its presence occasions all the incon-
veniences of all extraneous substance, that
would prevent a wound from uniting, and
an ulcer from  healing.   Hence, the de-
tachment of the protruded vesicle is very
justly indicated, and the success of the
plan is confirmed by practice; doubtless,
because  the  little transparent  tumour
can, in  general, be expeditiously remov-
ed, by  a stroke  of the curved convex-
edged scissars.   But  if, in some particu-
lar cases,  the vesicle should not pfoject
sufficiently from the  wound, or ulcer of
the cornea, to be included in the scissars,
the  same object may  be accomplished by
puncturing the tumour with a lancet, or
couching-needle; for, when  the  limpid
fluid which  Tit contains  is  discharged,
the  membrane forming it shrinks  with-
in the edges of tlie  wound, or ulcer of
the  cornea, and no longer  hinders the
union of the  former, or the cicatrizatioa
ofthe latter.
   Should the transparent tumour  reap-
pear in the same situation, the day after
its recision, or puncture, it is right to re-
peat one of these operations,  and to adopt
further  measures   for  maintaining the
wound of the cornea in contact; or, if it
should  be  an ulcer, the eschar must be
made to adhere more deeply to its bottom
and  sides,  so as to form a greater obsta-
cle than before  to the escape of the vitre-
ous humour.  In such circumstances, the
surgeon must take all possible care to ob-
viate such  causes  as  have a tendency to
propel the vitreous humour towards the
wound,  or  ulcer, of the cornea; particu-
larly too much pressure on  the eyelids,
spasms of the muscles of the eye, cough^
ing, sneezing, efforts at  stool, and other
similar  ones; and care must also  be
taken to check the progress of inflamma-
tion.
   Pellier's  two cases (Obs.  stir  I'QUil,
p. 350.) on the treatment of this species
of transparent vesicular  prolapsus, de-
serve perusal.  To these, if it were re-
quisite, Scarpa says he could add several
other similar ones, which  have  fallen
under his  own observation, in cases of
ulcer of the  cornea penetrating the ante- 
»   148          ISC
1SS
rior  chamber of the aqueous  humour,
and  which were attended  with as much
success as those  related by the  French
oculist.
  The choroid coat is,  likewise,  not ex-
empt from prolapsus.  Scarpa has  seen
and  cured this complaint  in M.  Bressa-
nir.i, an apothecary at Bescape.  A small
abscess, formed between  the sclerotica
and  choroid coats, at the distance of two
lines from the union of the cornea  with
the sclerotica, in the inferior  hemisphere
ofthe globe ofthe eye,  in consequence of
a severe internal and external ophthalmy,
which had been treated, in its incipient
state, with repellent remedies.  The ab-
scess burst, and discharged a small quan-
tity  of thick viscid lymph; then a  small
blackish body, composed of the choroid
coat, presented itself on the  outside  of
the  little  ulcer of the sclerotica.   The
treatment  consisted in  applying  tiie ar-
gentum nitratum several times to the pro-
jecting portion of the choroides, until it
was consumed, and reduced to a lexel with
the  bottom  of the  ulcer of the cornea.
Then the place healed.   The eye remain-
ed,  however, considerably weakened, and
the  pupil  became afterwards, so  much
contracted, that it  was almost  entirely
closed.  (Scarpa sulle Principali Malattie
degli Occlii. Venezia. 1802.)'
   Consult also Richter's Afangsgrunde der
 Wundarzneykunst, Band 3.  Von dent Vor-
falle der Regenbogenhaut.
   For a description ofthe manner of di-
viding the iris, in order to  make an artifi-
cial pupil, when the natural one is closed,
refer to Pupil, Closure  of
   A wound of the iris is one of the things
most to be feared  in extracting a cataract.
No  sooner does any instrument penetrate
the  eye, than the muscles of this organ
usually contract in a spasmodic manner,
so as to make great pressure on the part,
and to urge forward the cataract and the
iris.  In  this circumstance,  we cannot
wonder that  the  latter should  now and
then be injured by the edge of the instru-
 ment.  When the iris becomes entangled
 under the knife, Wenzel  asserts, that it
 may be invariably disengaged without in-
jury, by gently touching the cornea with
the  finger.  Richter justly observes,  how-
 ever, (Anfdngsgr. der Wundarzn ) that this
 artifice is  not unattended  with some risk
 of pressing out the aqueous humour;  es-
 pecially,  if the irritation of touching the
 eye should make it  move, or the opera-
tor  in the least disturb  the knife.  See
 Cataract.
   ISCHU'RIA.  (from   i<ry,u,  to restrain;
 and «£«v,  the urine.)   A  suppression, or
 stoppage of the urine.
  The distinction between a suppression
and retention of urine,  is practical and ju-
dicious.  The former most properly points
out a defect in the secretion of the kid-
neys ; the latter, an inability of* expelling
the urine when secreted. (Hey )
  The first disease is not very common,
is named ischuria renalis, or suppression of
urine, and belongs to the province of the
physician;  the second is an exceedingly
frequent disorder, is  named ischuria vesi-
calis, or retention of  urine, and its treat-
ment is altogether surgical. Every thing
relative to it will be found in the articles
 Catheter, and Urine,  Retention of.
  ISSUE signifies an  ulcer made design-
edly by the practitioner, and kept  open
a certain time, or even the patient s whole
 lite,  for the cure, or  prevention of a va-
riety of diseases.
  The physician,  in his practice, has fre-
quent occasion to recommend the makir.g
 of  an issue,  and the surgeon  finds it  a
 principal means  of relief  in several im-
 portant cases,  as, for instance, the white
 swelling, the  disease  of  the  hip-joint,
 caries of the vertebrae, &,c.   Many per-
 sons are  never  in  health, or, at least,
 fancy themselves always ill, unless they
 have an issue formed in some part of their
 body or another.  The making of  an is-
 sue,  indeed, is  not  unfrequently  con-
 sidered as  an imitation of nature, who,
 of her own accord, often forms ulcers and
 abscesses in various parts of the body (as
 is not uncommonly conjectured) for the
 purpose of  discharging pernicious hu-
 mours, whereby people are  supposed to
 be  freed from grievous disorders,  and
 have their health preserved.  The hu-
 moral pathologists were excessively par-
 tial to these notions, which, at the  pre-
 sent time, will be found by every  expe-
 rienced practitioner to influence the mass
 of mankind, and render the formation  of
 issues more common,  than  perhaps  is
 consistent  with  the better established
 principles of  medical science.   Few old
 subjects will  allow a sore of long stand-
 ing to be dried up (as the expression is),
 without requiring the surgeon immediate-
 ly afterwards to make an issue for  them.
 When an ulcer has existed a great length
 of time, the constitution may possibly be-
 come so habituated to it,  that the health
 may  really suffer from its being healed.
 Asthmatic complaints,  and  severe head-
 aebs are frequently observed to follow the
 cicatrization of  an old  ulcer; but, whe-
 ther  they  would have  happened,  if  an
 issue had been made in time, is a question
 difficult  of positive determination; for,
 many persons  with old  ulcers are  not
 prevented from suffering from  asthma,
 and headach.  The  plan  of making  an 
ISSUE.
149
Issue, however, is commendable  both as
rational and exempt from danger.  What-
ever may be the solidity* of the theories,
which have been offered by  medical  wri-
ters, in regard to issues, the practitioner,
who has his eyes open, cannot fail to see
the benefit often derived from such means;
and if there be  any unquestionable facts
in  medicine and surgery,  we may confi-
dently set  down  amongst  them  the fre-
quent  possibility of relieving one disease
by exciting  another of a  less grievous
and more curable nature.
   There are two  ways of  making an is-
si>e; one is with a lancet, or scalpel; the
other, with caustic.
   The place for the issue being fixed
upon,  the surgeon and his assistant are to
pinch up a fold of the integuments,  and,
 with a lancet or  knife, make in  them an
 incision of sufficient size to hold a pea, or
 as many peas  as may be thought proper.
 The pea, or peas are then to be placed in
 the cut,  and covered with a piece of adhe-
 sive plaster, a compress, and a bandage.
 The peas, first inserted, need not be re-
 moved for three or four days,  when  sup-
 puration will have begun ;  but, the  issue
 is afterwards to be  cleaned and dressed
 every day, and  have fresh peas  put  into
 it.  The  preceding is the ordinary me-
 thod of making  such issues, as are in-
 tended to contain only one or two peas.
    When the issue is "to be  larger, which
 is generally proper, in cases of  diseased
 vertebrae,  white  swellings, &c. the  best
 plan is to destroy a portion of the inte-
 guments with caustic.  The kali purum,
 blended with quicklime,  is mostly  pre-
 ferred for  this purpose.  The  situation
 and size of the issue having been deter-
 mined, the surgeon is to take care,  that
 the caustic does not extend its action to
 the surrounding parts.  With this view,
 lie is to take a piece  of adhesive plaster,
 and having cut a hole in it, of the exact
 shape and size of the issue  intended to
 be made, he is  to  apply  it to  the part.
 Thus the plaster will defend the adjacent
 skin from the effects ofthe caustic, while
 the uncovered  portion of integuments,
 corresponding to the  hole in the  plas-
 ter, is that which is to be destroyed.  The
 caustic is  to  be taken hold i>f with  a bit
 of lint, or tow, and, its end, having been
 a little  moistened  with water,  is to be
 steadily rubbed upon the part of the skin,
 where" the issue is to be  formed.   The
 frictions are to be  continued,  till the
 whole surface, intended to  be destroyed,
 assumes a darkish corroded  appearance.
  The caustic matter may now be  carefully
 washed  off'  with some  wet  tow.   The
 plaster is to be  removed,  and a linseed
 poultice applied.   As 60on as the eschar
is  detached, or  any part of it  is loose
enough to be cut away, without pain, or
bleeding, the peas are to be inserted and
confined in their proper place with a piece
of adhesive plaster.  Some use beans for
the purpose;  others beads;  which an-
swer very well,  and have the advantage
of serving  for any length of time, when
washed and cleaned every  day.  If the
issue is at all of a longitudinal shape, the
peas, beans, or beads, may be more easily
kept in their places,  when strung upon a
thread.
   Issues ought always to be made, if pos-
sible, in a situation,  where the peas  will
not be much disturbed  in the  ordinary
motions of the  body,  nor interfere with
the actions of muscles.  The interspaces,
between  the margins  and  insertions of
muscles, are deemed  the most  eligible
places. Thus, issues in the arms are usu-
ally made just at the inferior angle of the
deltoid muscle, by the side of the external
edge  of  the biceps.  In the lower extre-
mities, issues are often made at  the inner
side ofthe thigh,  immediately above the
knee,  in a cavity tiut  mo/be readily felt
there with the fingers.  Sometimes, issues
are made upon the inside of tlie  leg,  just
below the knee.  For the relief of any
affections of the head, or eye, the nape of
the neck is commonly selected as  a good
situation.  In caries of the vertebrae,  they
are'made on each side of the spinous pro-
cesses. In  cases of diseased hips,  they
are formed in  a depression just behind
and below the trochanter major.  When
the nature of the disorder does not parti-
cularly indicate the situation for the issue,
the arm should be preferred to  the leg,
as issues u). mi the upper extremities, es-
pecially the left arm, are much less an-
noying,than upon either of the lower limbs.
   The great art of keeping an issue open
for a long while, consists in maintaining
un equal and effectual pressure upon the
peas,  by which means, they are confined
in their places, little depressions are made
for them, and the granulations  hindered
from  rising.  Compresses of pasteboard
and sheet-lead will often be found highly
useful.  This plan is  the surest one  of
preventing  the   issue  from healing, and
the most likely to save the patient all the
severe and repeated suffering, which the
fresh  application of the  caustic, or the
use of stimulating powders, in order to
renew the sore  and repress tlie fungous
 flesh, unavoidably occasion.
   There  is  a  method of making issues
 with the caustic made in a sort  of paste,
 which is laid upon the part left uncovered
 by the adhesive plaster.  It seems to me
 to be a more tedious  and painful plan,
 and I do not recommend it. 
150
jei
  [Dr. Wistar has contrived a method of
forming issues, which is extremely sim-
ple  am', expeditious.—It consists in blis-
tering the skin, and rubbing it for two or
three minutes  with common  caustic.—
The caustic acts on the blistered surface
with great rapidity.]
  It has been suspected, that the  pain,
caused by the caustic  might be lessened,
by mixing opium with the application;
                JOI

but, the idea seems not at all probable;
tiie destruction of a part of the skin must
inevitably caus*;  considerable pain, with
whatever substance it  is  produced,  and
opium itself,  so  far from being likely to
diminish the agony, is  itself a violent sti-
mulus, whenever it comes  into contact
with  the  exposed extremities of  the
nerves.
1
J.
   JOINTS, DISEASES OF.  The joints
     are subject  to  numerous diseases,
which are more, or less, alarming, accord-
ing to their nature.   Like all other parts,
they are liable  to inflammation  and ab-
scesses ; their capsules frequently become
distended with an aqueous secretion, and
the disease termed hydrops articuli, is pro-
duced ;  but,  the  most important of all
their morbid affections,  are,  what  are
called,  white swellings, and  the disease of
the Hp-joint.

          WOUNDS OF JOINTS.

  Wounds ofthe large joints, made either
by puncture or incision, are of a very dan-
gerous  nature,  as these  parts are  sur-
rounded with tendinous and membranous
structures, which, though not very sensi-
ble in a sound state,  yet, when inflamed,
become  exquisitely   sensible, often at-
tended  with  vehement pain and fever,
and sometimes  with  delirious symptoms,
(SeeHunter's Commentaries, Parti,p.69.)
  Superficial  wounds of the  joints  are
often disagreeable cases;  but the danger
is always increased, when the injury pene-
trates the capsular ligament.  This event
may  be detected by the introduction of a
probe,  and often by a discharge of the sy-
novia, which is secreted by glands in the
joint to facilitate its motion.  But, as a
discharge of a similar kind,  may proceed
from mere wounds of such  bursx mucosx,
as he under the  tendons of muscles, in the
vicinity of joints,  our judgment might be
deceived, were  we unacquainted  with
the situation of these little  membranous
bags.  Wounds which  penetrate large
joints, must be looked upon as much more
dangerous,  than  those,  in Which  only
these bunsse are opened.
  When the large joints,  particularly the
knee, are wounded,  the  stomach is fre-
quently very much affected.   I remember
being shewn by  Mr.  Best of Newbury,  a
man, who,  in  his occupation as a wheel-
wright, happened to give  himself a wound
on one side ofthe knee:  a  good deal of
inflammation  and  suppuration ensued;.
but, what particularly struck me, was the
manner in  which the man complained of
the affection' of his stomach.
  In speaking of cartilaginous substances
in the joints,  we shall have occasion to
advert again to the  danger  attendant on
wounds of these parts.

        INFLAMMATION OP JOISTS.

  Idiopathic cases  of this  kind are 'not
common.   The  complaint ordinarily ori-
ginates, in consequence  of  a contusion,
sprain,  wound, or some other kind of in-
jury, done to the part affected-
  The inflamed joint shews the common
symptoms of  inflammation ; viz. preter-
natural redness, increased  heat, throb-
bing, pain, and swelling, while the con-
stitution is also disturbed   by  the  usual
symptoms of the inflammatory  fever.  It
is highly deserving notice,  however, that
in these cases, such symptoms are often
exceedingly severe, and the pulse is more
frequent, and  less  full and strong, than
when parts, more disposed to return to a
state of health, are affected.   The inflam-
mation first attacks some part of the cap-
sular ligaments, and  very quickly diffuses
itself universally over their whole extent,
as usually  happens  in all  inflammations
of smooth membranes.
  The capsules of the joints are naturally
not very sensible; but, Uke many  other
parts similarly  circumstanced, they be-
come  acutely painful,-  when  inflamed.
The complaint is accompanied with an in- 
JOINTS.
151
creased secretion of the synovia, which
becomes of a more aqueous, and of a less
albuminous  quality, than  it  is  in the
healthy state.  Hence, this  fluid is not so
well calculated for lubricating the particu-
lar surfaces, and preventing the effects of
friction, as  it is in the natural condition
of the joint.  This circumstance may ex-
plain, why a grating sensation is  often
perceived on moving the patella, when the
knee is inflamed.
  The  capsular ligaments,  like  other
parts, are  frequently  thickened  by  in-
flammation, and, sometimes,  coagulating
lymph, being effused on their  internal sur-
faces, organized.cartilaginous, or  osseous
bodies, are formed in their cavities.
  When-the inflammation  attains a high-
er pitch, an  abscess  may  occur in the
capsular ligament.  This  part at length
ulcerate's, and   the  pus makes  its way
beneath  the skin,  and  is  sooner, or
later, discharged through ulcerated open-
ings.
  An abscess rarely takes place in an im-
portant articulation,  in consequence of
acute inflammation, without the  system
being, also, so  deranged,  that life itself
is imminently endangered.  In the vio-
lent stage of tiie inflammation, just before
the abscess forms, very severe symptoms '
of  inflammatory fever afflict the  patient,
and, occasionally, delirium and coma tak«
ing place,  death itself ensues.
  In these cases, the inflammatory fever
is very quickly converted into the hectic;
indeed, when the abscess has taken place
in a large joint, in consequence of acute
inflammation,  hectic  symptoms  almost
immediately begin to shew  themselves,
and the strong actions of the common in-
flammatory fever suddenly  subside.
  Local consequences, even  worse than
those above described* may follow inflam-
mation of a .joint.  As the layer of the
capsular ligament, reflected over  the car-
tilages of  the  articulation is  often  in-
flamed, the cartilages themselves  are very
apt to  have tlie inflammation  communi-
cated to them.   Parts partaking of a car-
tilaginous  structure,  being very incapa-
ble or" bearing   the irritation  of  disease,
often  ulcerate,  or, in other   words, are
absorbed,  so as to leave a portion, or, the
whole, of the   articular surface  of the
bones, completely denuded of its natural
covering.  At length, the heads of the
bones themselves inflame, and become ca-
rious ;  or the consequence may be an an-
chylosjs.
   Sometimes, only such parts, as are ex-
terior to the capsular ligament, are affect-
ed, and,  in this case, tiie symptoms are
never so  severe, (Russell on  the  Knee, p.
60.) nor s«> obstinate, as when the com-
plaint  interests  the  capsular ligament,
and parts contained in it.  Even when an
abscess takes place on the outside of the)
capsular  ligament, the  case  cannot  be
considered as dangerous,  provided the
cavity of the joint be not involved in the
inflammatory  attack.  Every  inflamma-
tion of a large joint may be deemed a case
of considerable  importance.   I  do not
mean to assert, that  cases, in which the
inflammation is mild in degree, and sim-
ple in  its  nature,  are  dangerous •  no—I
only wish  to inculcate,  that  though the
inflammation  be originally genuine, it is
always very likely to be converted into
one of a specific nature, whenever there
is a tendency in  the system to scrofulous
disorder    A person, whose  constitution
is scrofulous, may sometimes continue,
during life, exempt from any1* local disease
of this specific  nature,  provided  he  be
fortunate  enough  to  avoid all irritation
of parts, on which scrofula is most par-
ticularly  disposed to make its attack.
Among such  parts we  must class the
joints,  especially  the  knee, hip,  elbow,
and  ankle.  Hence, when a joint  is  in-
flamed, how mild soever the affection may-
be, we ought  never to forget, that, when
there is  a tendency  to scrofula  in the
system, the original case of simple inflam-
mation is  very  apt  to  be the exciting
cause  of the white swelling, one of the
most  severe  and intractable diseases,
which  increase  the catalogue of  human
miseries.
  Hence,  the  curative  means should be
most rigorously put in execution, not.
merely on account of an abstract view of
the present state of the case;, but, also,
on account of the opportunity, which is
now afforded for a terrible disease to
arise,  which  often  remains  previously
dormant.
  It will considerably  shorten what  we
have to say concerning the treatment  of
inflamed joints,  to observe, that the anti-
phlogistic  plan, in the full sense  of the
expression, is to be strictly adopted. But,
as  there is a variety  of means,  often
adapted to the  same purpose, it  seems
necessary to offer a tew remarks on those,
which  lay  the greatest claim  to our com-
mendations.   The treatment of  an  in-
flamed knee  will serve to illustrate that
of all other large joints.
   There are few other surgical cases,  in
which general,  and,  especially  topical
bleeding is more strongly indicated.
   The violence  of the inflammation, and
the strength,  age, and   pulse of the pa-
tient,  must determine, with regard to the
use ofthe  lancet; but,  the topical  appli-
cation of  leeches may  be said to be inva
 riably proper.   When the leeches fall c*\ 
152                                JOINTS.
the'bleeding is to be  promoted by  fo-
menting the  part   The  surgeon should
daily  persist in this  practice, until the
acute stage of  the inflammation has sub-
sided-   But,  in conjunction  vyith  this
treatment, we  are to keep the joint con-
tinually surrounded with  linen wet with
the saturnine lotion.
  In a few instances, however, the pa-
tient seems to  derive more ease and be-
nefit  from the  employment of fomenta-
tions  and  emollient poultices, and the
feelings of the afflicted should always be
consulted ; for, if the pain be materially
alleviated by this,  or that application, its
employment will hardly ever be wrong.
  Nothing more need be said,  concerning
the rest of the  treatment, proper during
the vehemence ofthe inflammation, as the
duty of the surgeon is not materially dif-
ferent from what it is in other inflamma-
tory cases.
  As soon as the acute stage ofthe affec-
tion has subsided, the grand object is to
remove the effects, which have been left.
These are a thickened  state of the cap-
sular ligament, and parts surrounding the
articulations; a stiffness of the joint, and
pain,  when it is moved ;  a collection of
fluid in the capsule,  &c.   This state of
the complaint,  when neglected, and there
is a tendency to scrofula, may prove ex-
ceedingly obstinate; and  even terminate
in an  irremediable, specific distemper of
the joint.
  When this second stage of the disorder
seems tardy in going off, the  application
of  a blister  is  proper,  and it should be
kept open for a few days, by means  of the
savin cerate.
  In other cases, in which the inflamma-
tion has been more trivial, and the effects,
which it has left, are slight; lotions, com-
posed  of vinegar and sal-ammoniac, suf-
fice for tiie removal of  the chronic com-
plaints, continuing after tlie abatement of
the acute stage of the disorder.
  The severity of the constitutional symp-
toms  is mostly, if not  always, greater,
when  the  inflammation of a large joint
arises  from  a  wound,  than  when it is
the consequence  of a  bruise, or  sprain.
(See Treatise on the Diseases of the Joints,
1807.)

       LOOSE CAIITIIAGES IN JOINTS.

  The existence of extraneous  bodies in
the articulations is by  no means  a rare
occurrence, though unknown to the an-
cients.
  Pare is the first who speaks of this dis-
order:  he  says, that   a  hard, polished,
white body, of the  size ofanahnond, was
discharged from the knee of a patient, in
the year 1558, in which he had made an
incision for an aqueous aposteme, (without
doubt  an  hydrops articuli.)   Liv. 25,
.chap. 15.
  One  of  these  extraneous bodies was
found  on dissection in  a knee joint, by
Dr. Alexander Monro.  Mr. Simpson ex-
tracted  one of these some years   after-
wards, which at first  he did not suppose
was in  the cavity of the articulation, not-
withstanding its  mobility, and the  pain
it occasioned. (Edinb. Med Essays.) Since
these periods, examples have  been mul-
tiplied of this disease.
  Such detached and moveable cartilages
are not peculiar to the joint of the knee,
they oceasionally  occur in other joints of
the body;  but they  are most  frequently
met  with  in the  knee, and it is  in that
joint that they produce symptoms which
render them the  object of a  chirurgical
operation.   Morgagni has seen them in
the ankle ; Haller in the joint  of the jaw;
and Hey in the elbow.
   These substances, m their structure,
are,  as Mr. Home remarks, analagous to
bone;  but, in their external appearance,
bear a greater resemblance to cartilage.
They  are  not, however, always exactly
of the same structure,  being in some in
stances  softer,  than in others.   Their
external surface is smooth and polished,
which, being lubricated by the synovia,
allows them to  be moved readily from
one part ofthe joint  to another;  seldom
remaining  long at rest,  while the  limb is
in motion; when  they  happen to  be in
such  situations  as to  be pressed upon
with force by the different parts  of the
joint,  they  occasion considerable pain,
and  materially interfere with its  neces-
sary motions.
   The circumstance of their being loose,
and  having no remains of a visible at-
tachment,  made  it difficult to form con-
jectures respecting their formation; and
according  to  Mr. Home, no  satisfactory
account  of their  origin had  been given,
till Mr. Hunter's observations  threw light
upon  the  subject.   The  circumstances,
which led him  to  the investigation  of
this subject, appear  at first sight so fo-
reign  to the purpose, that they require
some explanation.
   In the course  of his experiments and
observations, instituted with  a view  to
establish a living principle in the blood,
Mr. Hunter was naturally induced  to at-
tend  to  the phenomena, which  took
place, when that  fluid  was extravasated,
whether in consequence of accidental vio-
lence, or other circumstances.  The first
change  which took place he  found to be
coagulation;  and the  coagulum  thus
formed,  if jn contact with living parts, 
JOINTS.
l5o
 •ml not produce  an irritation similar  to
 extraneous  matter, nor was it  absorbed
 and  taken  back into the constitution,
 but,  in many instances, preserved its liv-
 ing principle,  and became vascular, re-
 ceiving  branches  from the neighbouring
 blood-vessels for its  support;  it  after-
 wards underwent changes, rendering it
 similar to the parts to which it was at-
 tached,, and  which supplied it  with nou-
 rishment.
   In  attending to cases of this kind, he
 found that where a coagulum adhered to
 a  surface,  which varied  its  position,
 adapting it to the motions  of some other
 part ; tiie attachment  was necessarily di-
 minished by  the  friction,  rendering it in
 some instances pendulous; and  in others
 breaking it off entirely.
   Hence it was easy to  explain the mode
 in  which  those  pendulous bodies are
 formed,  which arc sometimes attached to
 the inside of circumscribed cavities, and
 the principle being established,  it became
 equally easy for Mr.  Hunter to apply it
 under other circumstances,  since it is evi-
 dent  from  a  known  law  in the animal
 economy, that  extravasated blood, when
 rendered an  organized part of  the body,
 ean assume  the nature of the parts into
 which it is effused, and consequently, tiie
 same coagulum which in  another situa-
 tion might form  a soft tumour, would
 when situated on a bone, or in the neigh-
 bourhood of bone,  often form a hard one.
 The  cartilages found  in  the knee-joint,
 therefore, appeared to  him to  originate
 from a deposit of coagulated blood upon
 the end of one of the  bones, which had
 acquired the nature of cartilage, and had
 afterwards been separated.   This opinion
 was further  confirmed  by  the  examina-
 tion of joints which had  been  violently
 strained, or otherwise injured, where the
 patients had died at different periods af-
 ter the accident.  In some of these there
 were small projecting  parts, preternatu-
 rally  formed, as hard  as  cartilage, and
 so situated, as to  be readily knocked off
 by any sudden,  or  violent motion of the
joint. ( Transactions of a Society for tlie Im-
provementof Medical and Chirurgical Know-
ledge, Vol  1 )
  One or more of these preternatural bo-
dies may be formed  in the same joint.
 Mr. Home mentions one instance  in which
there were three; they are commonly
about the  size  of  a horse-bean, often
much smaller, and sometimes considera-
bly larger; when very large, they do not
give so much trouble to the patient as tlie
smaller  kind.  A soldier in the 56th re-
giment  has one nearly as  big  as the pa-
tella,  which  occasions  little uneasiness,
being too barge to insinuate itself into the
    Voi. ir.
 moving parts of the joint.  Morgagni has
 seen twenty-five in one joint.
   If we except making an  incision into
 the joint, tor the purpose of extracting the
 cartilaginous tumours, we  are not  ac-
 quainted with any certain means of free-
 ing a .patient from the inconvenience of
 this complaint.  To  this plan, the dan-
 ger attendant on all  wounds of so large
 an articulation as the knee, is a very se-
 rious objection.  Middleton and  Gooph
 endeavoured to  conduct the extraneous
 body into a situation, where it produced
 no pain,  and to retain it in that  position,
 a long time,  by bandages, under the idea,
 that the cartilaginous  substance  would
 adhere to the contiguous parts, and  oc-
 casion no future trouble.  Some will be
 inclined  to think,  that no  positive con-
 clusion ought to be drawn from the cases
 brought forward by these gentlemen,  be-
 cause they had no opportunity of  seeing
 their patients again at the end of a rea-
 sonable  length of  time, and  we  know,
 that loose cartilages in the joints, some-
 times disappear for half a year, and then
 make their appearance again.   Yet, per-
 haps, the very  circumstance  of the pa-
 tients not applying  again, may  appear to
 many to justify the inference, that suffi-
 cient relief had been obtained.  _
   Mr. Hey, impressed with a just sense
 ofthe dangerous symptoms, which have
 occasionally resulted from the  most sim-
 ple  wounds  penetrating the knee-joint,
 very laudably tried the efficacy of a laced
 knee-cap, and tlie  cases, which  he has
 adduced, clearly demonstrate,  that the
 benefit,  thus  obtained, is not temporary,
 at least,  as long as the patient cont :nues
 to wear  the  bandage.  In one  case, the
 method had been tried for ten years, with
 all the success,  which the. patient  could
 desire.
  Contemplating the evidence, which we
 have upon this point, and  the  perilous
 symptoms,  sometimes  following wounds
 ofthe knee-joint, I am decidedly of opi-
 nion, that the effect of a knee-cap,  or of
 a roller and  compress, applied over the
 loose cartilage, when  this body is  so si-
 tuated as not to create pain, and to ad-
 mit of being compressed, ought generally
 to be tried, before having recourse to ex-
 cision.   1 say generally, because the con-
 duct of the surgeon ought, in such cases,
 to be adapted to the condition, and  in-
 clination of the patient,  ff a man be de-
 prived of his livelihood by not being able
 to use his knee;  if he  cannot, or will not
 take the trouble of wearing a bandage;
if he be urgently desirous of running the
risk of the operation after things nave
been impartially explained to  him; if a
bandage should not be productive of sut-
    U 
154                                JOINTS
 ficient relief;  and, lastly,  if excessive
 pain,  severe inflammation  of the joint,
 and lameness,  should  frequently be pro-
 duced by the  complaint; I think  it is
 the duty  of  a  surgeon to operate.  It is
 very certain, that success has generally
 attended the operation ; but small  as the
 chance is  of losing the  limb, and even
 life, in the attempt to get rid of  the dis-
 ease ; yet, since the inconveniences ofthe
 complaint are, in most cases, very bear-
 able,  and are  even capable  of palliation
 by means  of a bandage, endangering the
 limb and life  in any degree, must  seem
 to many persons contrary to the  dictates
 Of prudence.   I am ready  to  allow, with
 M. Brochier, that the danger, attendant
 on wounds ofthe large joints, has always
 been exaggerated  in  consequence of An-
 cient prejudices.  (Desault's Journal, Vol.
 2.) But,  making every allowance for the
 influence  of  prejudice, a  man must  be
 very sceptical indeed,  who does not con-
 sider the wound of so  large a joint as the
 knee, attended with real cause for the ap-
 prehension of  danger.  See Case  2, in
 my Treatise on the Diseases  of the Joints.
 At the end of Mr. Ford's case, (Med Obs.
 and Inquiries, Vol. 5.) we read on the sub-
ject of cutting loose cartilages out of the
 knee: " The society have been informed
 of several  cases, in  which the operation
 has been  performed; some, like  this,
 have healed  up, without any  trouble;
others have  been  followed with violent
 Inflammation, fever, and death itself."
   As the disorder is often attended with
 a degree of heat and tenderness in the ar-
 ticulation ; as the danger of the operation
 is, in  a great  measure,  proportioned  to
 the subsequent  inflammation;  and,  as
 mueh  of  the danger is at once removed,
if the wound unite by  the first intention  :
 the advice, to  keep the patient in bed, a
few days before operating, to apply leech-
es, and cold  saturnine  lotions to the knee
during the same time,  and to exhibit be-
forehand  a  saline purgative, is  highly
prudent.
   I shall next introduce an account of the
plan of operating, as described by several
 of the best modern surgeons.
   " As these loose bodies cannot  always
be found,  no time can be fixed  for the
operation ; but the patient, who will soon
become familiar with his own complaint,
must arrest thenr when  in a favourable
situation,  and  retain them there till the
surgeon can be sent for.
   " Before the operation, the limb should
be extended upon a table in an horizontal
position, and secured by means of assist-
ants ; the loose cartilages  are to be push-
ed into the upper part of the joint above
the patella, and then   to  one side; the
 inner side  is  to be preferred, as in that
 situation only the vastus internus muscle
 will be divided in the operation.  Should
 there be  several  of these bodies, they
 must be all secured, or  the  operation
 should be postponed  till some more fa-
 vourable opportunity, since the leaving of
 one will subject  the patient to the  repe-
 tition of an  operation, not only painful,
 but attended with some degree of danger.
   " The loose  bodies are to be secured in
 the situation above-mentioned  by an as-
 sistant,  a task not easily performed while
sthey are cut upon, from their beir.g lu-
 bricated by the synovia; and if allowed to
 escape into the general cavitv, they may
 not readily, if  at all, be brought back into
 the same situation.
   " The operation consists in making an
 incision upon  the loose  cartilage, which
 it  will be best to do in the direction of
 the thigh, as the wound will more readily
 be healed  by the first intention. If  the
 skin is drawn  to one side,  previously to
 making the incision, the wound through
 the parts uiaderneath will not correspond
 with that made in the skin, which circum-
 stance  will favour their union.  The  in-
 cision upon the cartilage must be made
 with caution, as it will with difficulty be
 retained in its  situation if much force is
 applied.  The  assistant  is  to endeavour
 to push the loose body through the open-
 ing, which must be made sufficiently large
 for that purpose; but as thi s cannot al-
 ways be done, the broad end of  an eyed
  firobe may be  passed under  it, so as to
  ift it out, or a sharp-pointed instrument
 may be stuck into it, which  will fix it to
 its situation, and bring it more within the
 management ofthe surgeon.
   " The cartilages being  all extracted,
 the cut edges of  the wound are to  be
 brought together, and, by means of a com-
 press of lint, not only pressed close to one
 another, but also to the parts underneath,
 in  which situation they are to be retained
 by sticking plaster,  and the uniting band-
 age.
   " As  union by the first intention  is of
 the utmost consequence after this opera-
 tion, to prevent an inflammation of the
 joint, the  patient  should  remain in bed
 with the leg extended, till  the wound is
 perfectly united,  or at least all chance of
 inflammation at an end,."  (Home,  in Med.
 and Chir. Transactions, Vol 1, p. 239, &c)
   fn  one instance, Desault proceeded in
 the following manner : the surgeon,  after
 relaxing the capsular ligament  by ex-
 tending  the leg,  brought the extraneous
 body on the inside  of  the articulation
 against the attachment of  the capsular
 ligament, and secured it in this situation
 between the m.lex  finger and  thumb-yj 
JOINTS.                               165,
the left hand, whilst an assistant drew
the integuments forwards towaids the pa-
tella.   All the parts that covered this ex-
traneous body  were  now divided  by a
longitudinal incision, one inch in  length,
and its extraction accomplished by push-
ing it from above downwards, and raising
it inferiorly with  the end of the  knife.
This  substance,  on  examination  was
found similar in colour to  the cartilages
that cover the articular surfaces:  it was
three  quarters of an inch in  length, six
lines  and an half in width,  and three
lines  in thickness;   its surfaces  were
smooth, one concave and the other  con-
vex;  its circumference  irregular, disse-
minated with red points, forming small
depressions;  the inside  was ossified, the
outside of a cartilaginous texture.  As
soon as the substance "ways  extracted, the
assistant let go the integuments which he
had drawn forwards; they consequently
returned to their natural situation, on the
inner   side of the knee-joint, in such a
manner, that  the external  wound in the
integuments  was situated  more inwards
than  the one in the capsular ligament.
Two  advantages were procured  by this
means:  on the one  hand, air was  pre-
vented from  penetrating into the articu-
lation; and on the  other,  the  floating
portion of capsular ligament, retained in-
wards by the skin, was more  likely to at-
tach itself  to the condyle, in case it did
not unite to the other portion of the cap-
sule divided near its attachment.  The
edges of the wound  were brought in con-
tact by means of a uniting bandage; dry
 lint and compresses were applied, and
retained on tiie part  by  a slight bandage;
the limb was kept in a state of extension.
 (Desault's Plan, as described by Brothier in
 Desault's Journal, Tom. 2.)
   The  inner  surface  of  the  internal
condyle of the os  femoris presents an ex-
tensive and nearly plain  surface, which
 terminates in front and  at its upper part
 by an edge  which forms a  portion of a
 circle.   If the points  of the finger be
 firmly  pressed upon this edge so as to
 form  a kind  of  line of circumvallation
 round these ^cartilaginous)  bodies, they
 cannot pass into the joint in this direction,
 nor can they recede in any other, on ac-
 countof the tense  state of the.  internal
 lateral ligament.  Here these substances
 are near the  surface,  and  may  be dis-
 tinctly felt;  and there is  nothing to be
 divided in order  to expose them, but the
 integuments, fascia, and the capsule of
 the joint.
   In an interesting case, which Mr, Aber-
 nethy relates,  he observes:  " The opera-
 tion  was done in the  following manner.
 Sir  Charles  Blicke,  who  assisted me,
 pressed the  integuments  of the  knee,
 gently towards the internal condyle, and!
 then applied his fingers  in the manner I
 have described, round the circular edge
 ofthe bone.  I also drew the integuments
gently towards the inner ham-string, and
 divided them longitudinally, immediately
 over the loose substance, to the extent of
 an inch and  an half.  This withdrawing
 of the integuments from their natural  si-
 tuation was designed to prevent a direct
 correspondence in the situation of the ex-
 ternal wound, and that of the capsule of
 tlie joint; for when-the integuments were
 suffered to regain  their natural position,
 the wound in them was nearer to the pa-
,tella, than the wound which was made in,
 the capsule.   The fascia which covers the
 joint  being  exposed  by the division of
 the integuments, it was divided in a simi-
 lar direction, and nearly to the same ex-
 tent.   The capsule  was now laid  bare,
 and I gently divided it to the extent of
 half an inch, where it covered one of the
 hard  substances,  which suddenly flipped
 through the opening, and  by pressing
 gently upon the other, it also came through
 at  the  same part.  The  bodies  which
 were thus removed,  were about  three
 quarters of an inch in length, and half an
 inch in breadth.  They had a highly po-
 lished surface, and were hard like carti-
 lage.  The  fluid  contained in  the joint
 was pressed towards the wound, and about
 two olhnces  of synovia were  discharged.
 I then drew the wound of the integuments
 gently  towards the patella, pressed the
 two sides together, and closed it accurate-
 ly  with  sticking plaster, enjoining  the
 patient to keep the limb as free from mo-
 tion as possible."   (Surgical Observations,
 1804.)
 •  On the preceding subject some  obser-
 vations have been lately published by  M.
 Larrey. (See Memoires de Chirurgerie Mi-
 litaire, torn. 2, p. 421, fcfe.)  With  the ex-
 ception of a few  wrong theories, he ap-
 pears to have given a very fair account of
 the disease.

            HYDROPS ARTICCTI.

   This  signifies  a collection of  serous
 fluid in the capsular ligament of a joint.
 The complaint is attended  with more or
 less swelling, and a fluctuation, but, there
 is, in  general, but little pain.  The af-
 fection is sometimes situated in the burs?e
 mucosae.  The knee is more subject, than
 other joints, to  dropsical disease.  The
 complaint is frequently preceded by severe
  rheumatic affections,  and a local injury of
  tiie part.  When the fluid is not so copious
  as to produce very great distention of thp
  capsule, a fluctuation is easily distinguish- 
156                               JOINTS.
able.  Also, if the 1 imb be extended, so as
to relax the ligament of the patella, press-
ing the collection of fluid causes a rising
of that bone, and a fulness on each side
of it.  The  disease, though unattended
With  much  pain, produces  a degree of
rigidity in the joint.               _ _
  Mr- Russell  has  adopted the opinion,
that some cases of this kind are venereal,
and others scrophulous; but, he has not
supported the doctrine on any solid foun-
dation.  Hydrops articuli sometimes fol-
low fevers.
  The cure of the above described drop-
sical affection of the joints, depends upon
the absorption of the effused fluid. Such
absorption is sometimes  altogether spon-
taneous,  and the event may always be ex-
cited, and promoted, by mere friction, by
rubbing the joint with camphorated mer-
curial ointment, by repeatedly  applying
leeches, and particularly,  by the employ-
ment of a perpetual blister.
  The operation of a blister may always
be very, materially assisted by a bandage^
applied with moderate tightness.  Among
other effectual means of cure, we  may
enumerate  frictions with flannel  impreg-
nated with the fumes of vinegar; electri-
city ; and tiie exhibition of mercurial me-
dicines to open the bowels. When"hydrops
articuli occurs during the debility, conse-
quent to typhoid, and  other fevers,  the
complaint can hardly be expected to get
well before  the patient has regained some
degree of strength.               j
   Circumstances do not often justify mak-
ing an opening imo the joint; but, exces-
sive  distention, in some neglected cases,
might certainly be an urgent reason for
performing such an  operation.  Also,  if
the complaint should resist all other plans
of treatment,  and the irritation of the tu-
mour greatly impair a weak constitution,
the practice would be justifiable.  An in-
teresting example of this kind is related
by Mr. Latta.   (System of Surgery, Vol. 2.
p. 490.)
   It is best to make the opening in such a
 way, that the wound in the capsular liga-
ment after the operation, will not remain
directly  opposite the  wound in the skin.
For this purpose, the integuments are to
 be pushed to one side, before the surgeon
 m ikes an incision through them.  (Ency-
clopedic  Method. Part. Chir. Art Hydro-
pisie des Jointures.)

     COLLECTIONS OF UL00D IN JOINTS.

   Most  systematic writers  speak of this
 kind of case, though it is certainly a very
 uncommon one.   Tumours,  about  the
joints,  composed of blood, and set down
in numerous surgical works, as extravasa-
tions within  tlie capsular  ligament, are
gen .rally on the outside of them.
  Certainly, were a collection of  fluid to
take place in a joint very suddenly, after
a sprain/or contusion, and to continue to
increase  gradually, for some time after-
wards, there would be reason for  believ-
ing, t^at most of the contents of the tu-
mour was blood.  The production of an
abscess,  and the  secretion of any fluid,
would have required a longer time.
   Were blood known to be  undoubtedly
effused in  a  large articulation,  no  man
would be justified in making an  opening
for its discharge.  No bad  symptoms are
likely  to result from its mere presence,
and the absorbents will,  in the end,  take
it away.   Should an incision be made into
the joint, the coagulated state of the ex-
travasated blood  would frequently not
allow -such blood to be discharged.
   The best plan is to apply discutient re-
medies ;  a lotion of vinegar  and  sal am-
moniac is the best application for the first
three or four days, and, afterwards  fric-
tions with  camphorated  liniments may be
safely had recourse to.
   Mr. Hey has related a case, in which
the  kqee-joint  was  wounded, and blood
insinuated itself into the capsular  liga-
ment ; yet, though the occurrence could
not be hindered, no  harm resulted  from
tiie extravasation which was absorbed,
without having created the smallest incon-
venience.  (Practical Observations in Sur-
gery^. 354.)


            WHITE SWELLING.

   The white swelling, or spina ventosa,as
 it is  not unfrequently called, in imitation
 ofthe Arabian  writers,  Hhazes and Avi-
 cenna,  is  in this country,  a peculiarly
 common, and an exceedingly terribledis-
 ease.  As I have stated in my Treatise on
 tlie Diseases of tlie Joints, the people ofthe
 continent are, unquestionably, as subject
 as we are to chronic enlargements of the
 knee-joint.  Foreign  surgeons  describe
 numerous varieties  of a  disease, which
 mai<y English  writers would term,  rheu-
 matic  white swellings, but they  acknow-
 ledge, that the scrophulous species of this
 disorder does not commonly  occur to their
 nctice.  (Kortum de*Vitio Scrophuhso, Vol
 2 p. 333.   BrambiUa in Acta Acatl. Med.
 C/ur. Vindobonensis, Vol 1. p. 20.  Petit sur
 les Maladies des Os,  Vol. 2. p. 359.  Edit.
 1749.)
   Wiseman was the first who used the
 term White-Swelling; and the expression
 is not very  unapt, because it conveys an
 idea of one mark of the  distemper, which
 is, that notwithstanding the increase  tft 
JOINTS.
U?
size in tiie joint, tlie skin is not inflamed,
but retains its natural colour.  (Pott.)
  The varieties ol white-swellings are very
numerous, and might usefully receive par-
ticular appellations.  Systematic writers
have  generally been content with a dis-
tinction into two kinds, viz. rheumatic, and
scrophulous.
  The last species of the disease they  al-
so distinguish into  such tumours as pri-
marily affect the bones, and then the liga-
ments and soft parts; and into other cases
in which the ligaments and soft parts be-
come diseased, before there is any morbid
affection of the bones
   These  divisions of the subject appear
hardly comprehensive enough  and  the
propriety of  using the  term,  rheumatic,
seems very questionable.
   Sometimes  the bones, ligaments, and
cartilages, are hardly at all diseased. The
whole disease of the joint appears to arise
from  an extravasation of  glutinous lymph,
 which is intimately radherent to the most
subtile layers of the cellular  substance,
and to the surface of the tendons, liga-
ments, and capsule of  the  articulation.
This distemper  has been named by Bram-
billa, Fungus Articulationis.  Acta Acad.
 Medico-Chirurg:  Vindob  p. 1.
 ♦  Sometimes, the  bones are not in the
least diseased,, though the ligaments and
 cartilages are much altered, the joint is
 immensely enlarged, and the severity  of
 the disease has even rendered amputation
 indispensable.
   Sometimes, the  ligaments,  cartilages,
 and bones are not  the  parts,  which are
 chiefly distempered.  In the instances, al-
 luded to, the articulation is greatly  in-
 creased in size, but, most of tlie swelling
 originates  from a  diseased  state of the
 parts on the outside of the capsular liga-
 ment.  The disease does not consist of a
 thick kind of lymph, diffused throughout
 the structure  of the parts  on the outside
 of the joint;  but, of a morbid change,  in
 which such parts become at once enlarged,
 thickened, and bereft of all their original
 firmness   Very frequently, the texture of
 the heads of the  bones is softened, the
 ligaments are distempered, the cartilages
 absorbed, and the  bones carious.
   Sometimes, the surface of the diseased
 bones are rendered  rough and irregular
 by tlie secretion of a kind of substance like
 spermaceti in appearance, but, containing
 a proportion of phosphate of lime.
   It  has  been too commonly inculcated,
 that  the bones are  always carious  in this
 disease   But, as I have explained, caries
 only comes on in an advanced stage of  the
 malady.  The idea of there  being  invari-
 ably  a carious  affection of the bones led
 the old surgeons into the most unwarrapt-
able practices, with a view of promoting
the process of exfoliation.
  In numerous cases, in which the articu-
lation is considerably enlarged, the heads
of" the bones are entirely  fee from dis-
temper. Mr. Russell has noticedhow much
the soft parts frequently contribute to the
swelling.  He describes the  appearances
on dissection thus :  " The  great  mass of
the swelling appears to arise from an af-
fection of the parts, exterior to the cavity
of the joint, and which, besides! an en-
largement  in size, seem also to have un-
dergone a material  change  in structure.
There is a larger, than natural,  jfropor
tion of a viscid fluid, intermixed With the
cellular substance;  and the cellular sub-
stance itself has  become thicker, softer,
and of a less firm consistence, than in a
state of health." (On  the Morbid Affec*
tions ofthe Knee, p. 30.)
  We may infer from  what  Mr. Russell
states, that he is inclined to believe, that
the disease always begins in the ligaments
and membranes  of tlie articulation, and
he even asserts, that lie had never heard nor
known of an instance, in which tlie tibia was
enlarged from an attack of white siuelling.
P. 37.  It is still a very prevailing notion,
that, in white swellings, the heads of the
bones are preternalurally enlarged.
  Deceived by the feel  of many diseased
joints, and influenced by general opinion,
1 once imbibed  the idea, that there is very
frequently a regular  expansion  of  the
heads . of scrophulous bones.  But,  ex-
cepting an occasional enlargement, which
arises from spiculz of bony matter, depo*
sited on the outside ofthe tibia, ulna, &c.
and which alteration cannot be called  an
expansion of those  bones,  I have  never
been an eye-witness of the head of a bone
being of preternaturally large dimensions,
in consequence  of the disease known  b.y
the name of white swelling.   I have often
been in the habit of inspecting the state cf
the numerous diseased joints, which are
every  year amputated  at St. Bartholo-
mew's Hospital, and though 1 have long
been attentive to this point,  my searches
after a really enlarged scrophulous bone
have always been in vain.   The  change,
which the head of the tibia undergoes in
many  cases, is first a partial absorption
of  the phosphate of lime throughout  its
texture, while a soft kind of matter seems
to  be secreted  into its substance.  In a
more advanced stage, and, indeed, in that
stage, which most frequently takes place
before a joint is  amputated, the head o*r*
the bone  has deep excavations  in conse-
quence of caries, and its structure is now
so  softened, that when an  instrument ia
pustied against the carious part,  it easily
penetrates deeply into the bone. 
158
JOINT*.
  A cursory examination of  a diseased
joint, even when it is cut open, will not
suffice to shew, that the heads of the bones
.have iot acquired an increase of size.  In
making a dissection of this kind, in the
presence of a medical friend, I found, that,
even after the joint had been opened, the
swelling had every appearance of arising
from  an actual  expansion  of  the  bones.
iThe gentleman with me felt the ends of
the bones after the  integuments had been
removt$l, and he coincided with me, that
the feel, which  was even now communi-
cated, seemed to be caused by a swelling
ofthe bones themselves. But, on cleaning
them, the enlargement was demonstrated
to arise entirely from a thickening of the
soft parts.  I  am  glad to find, that Mr.
Crowther is among those, who now disbe-
lieve in the doctrine of expanded scrophu-
lous bones.  (See Practical Observations on
White  Swelling, &c. Edit. 2. p. 14.1808.)
  The  soft parts  undergo  a material
change; they are both thickened and sof-
tened, and there is a large quantity of  a
viscid fluid, intermixed with the cellular
substance.  In short,  the  whole texture
of tlie cellular membrane becomes thicker
and softer, than in the healthy state.
  In the cavity of the joint,  we sometimes
find a quantity of curdy matter, and the
cartilages absorbed in various places, but,
more particularly round the edges ofthe
articular surfaces.
   The  knee, ankle, wrist, and elbow,  are
the joints most subject to white swellings.
As the  name of the disease implies,  the
skin is  not at all  altered  in  colour.  In
some instances  the swelling  yields  in  a
certain degree to pressure; but it never
pits,  and  is  almost always  sufficiently
firm to make an uninformed examiner be-
lieve, that the Ajones contribute to the tu-
 mour.  The pain is sometimes vehement
from the very  first;  in other instances
there is hardly the least pain in the be-
ginning of the disease.  In the majority
of scrophulous white-swellings,  let  the
pain  be trivial, or violent, it is particu-
larly situated in  one  part of the joint;
viz. either the centre of the articulation,
or  the head of the tibia. Sometimes,  the
pain  continues  without   interruption;
 sometimes there are intermissions ;  and,
 in other instances,  the pain recurs at re-
 gular times, so as  to have been called by
 some writers, periodical.  Almost all au-
 thors  describe  the patient, as suffering
 more uneasiness in the diseased part, when
 he is warm, and, particularly, when he  is
in this condition in bed
   At the commencement ofthe disease  in
 the majority of instances,  the swelling is
 very inconsiderable, or there is even no
 visible  enlargement whatever. InthelittJr
depressions,  naturally seated  on  eacl4'
side ofthe patella,  a fulness first shewn
itself, and gradually spreads all over the
affected joint.
  The patient,  unable to bear the weight
of his body on  the disordered joint,  iii
consequence  of the great increase of pain,
thus created, gets  into the habit of only
touching the ground with  his  toes, and
the  knee  being  generally kept  a little
bent in this manner, soon loses the capa-
city of becoming  completely  extended
again.  When white swellings have lasted
a good while, the knee is almost  always
found in a permanent state  of flexion.  In
scrophulous cases of this kind, pain con-
stantly precedes any appearance of swell*
ing;  but  the  interval between the two
symptoms differs very much in different
subjects.
  The morbid joint, in the course of time,
acquires a vast magnitude.  Still the in-
teguments retain their natural colour, and
remain  unaffected.   The enlargement  of
the articulation,  however,  always  seems
greater than' it really is, in consequence of
the emaciation of the limb both above and
below the disease.
   An appearance of blue distended veins,
and a shining smoothness, are the only al-
terations to be noticed in the skin covering
the enlarged joint.  The shining smooth-
ness seems attributable to the  distention,
which obliterates the natural furrows and
wrinkles  ofthe cutis.  When the joint is
thus swollen, the integuments cannot be
pinched up  into a fold,  as they could in
the state of health, and even in the be-
ginning of the disease.
   As the distemper of the articulation ad-
 vances, collections of matter form around
 the part, and at length burst  The ulcer- •
 ated openings  sometimes  heal up ; but,
 such abscesses are generally followed by
 other collections, which pursue the same
 course.  In some cases, these  abscesses
 form a few months after the first affection
 of the joint; on other occasions,  several
 years elapse, and no suppuration of this
 kind makes its appearance.
   Such terrible local mischief must neces-
 sarily produce constitutional disturbance.
 The patient's health  becomes gradually
 impaired, he loses both his appetite and
 natural rest  and sleep ;  his pulse is small
 and frequent;  an obstinate  debilitating
 diarrhoea, and profuse nocturnal sweats,
 ensue.   Such complaints are, sooner or
 later, followed by dissolution, unless the
 constitution  be relieved in  time, either by
 the amendment, or removal of the diseased
 part.   In different patients, however, the
 course of the disease, and  its effects upon
 the system,  vary very much in relation to
 the rapidity with whiqh they occur. 
JORtfTft
159
   Rheumatic  White-Swellings  are very
 distinct  diseases from  the  scrophulous
 distemper of the large joints. In the first,
 the pain is  said never to occur without
 being attended with swelling.   Scrophu-
 lous white-swellings, on the other hand,
 are always preceded by a pain, which is
 particularly confined to one point of  the
 articulation.   In  rheumatic  cases,  the
 pain is more general, and diffused over
 the whole joint.
   It seems  probable,  that  all cases, in
 which  the structure of the bones is found
 quite  undiseased, and  in  which all  the
 mass of disease seems  to be confined to
 the soft parts,  are not scrophulous white-
 swellings.  Few  persons, who  have  at-
 tained  the age of five and twenty, without
 having  had the least  symptom  of scro-
 phula,  ever experience, after this period
 of life, a first attack of the white-swelling
 ofthe  strumous kind. All cases, in which
 the internal structure of the heads of  the
 bones becomes softened, are probably scro-
 phulous.
    Mr.  Russell has noticed the frequent en-
 largement of the lymphatic glands in the
 groin,  in consequence of the irritation of
 the disease when  in the knee; but, he
 justly adds, that this secondary affection
 never proves long troublesome.
    When the bones are diseased, the head
 ofthe  tibia always  suffers more than the
 condyles  of the  thigh bone.  (Russell.)
 The articular surface of the femur some-
 times  has not  a single rough  or carious
 point,  notwiihstanding  that of  the tibia
 may have suffered a great deal.   The car-
 tilaginous coverings of the  heads of  the
 bones are generally eroded  first at their
 edges; and, in the knee, the cartilage of
 the tibia is always more affected than that
 covering the condyles of the thigh bone.
 Indeed, when white-swellings  have their
 origin  in the bones, and the knee is  the
 seat of the disorder, there is some ground
 for supposing,  that it is in the tibia, that
 Jthe morbid mischief first commences.
   The ligaments of the knee are occasion-
 ally so much weakened,  or destroyed, by
 this terrible malady, that the  tibia  and
 fibula  become, more  or less, dislocated
 backward, and drawn towards the tube-
v rosity ofthe ischium, by the powerful ac-
 tion of the flexor muscles of the leg.
   I have seen a curious species  of white-
 swelling, in which the leg  could be bent
 to each side in a very  considerable  dis-
 tance,  both when the knee was extended
 and bent.  Such a state implies a preter-
 natural looseness of the ligaments of the
 articulation.
    With respect to the particular causes of
 all such white-swellings, as come within
 the class of rheumatic opes, little is known.
External irritation,  either by exposure to
damp  or  cold, or by the application of
violence,  is often concerned in bringing
on  the disease; but, very frequently, no
cause of this kind can be assigned for the
complaint.  As  for scrophulous white-
swellings, there can be no doubt, that they
are under the  influence of  a particular
kind of constitution, termed a scrophulous
or strumous habit.   In this  sort of tem-
perament, every cause capable of exciting
inflammation, or any morbid and irritable
state of a large joint, may bring on such
disorder as may end in the severe disease
of which  we are now speaking.
  In a man of a sound constitution, an ir-
ritation ofthe kind  alluded to, might only
induce common  healthy  inflammatioft of
the affected joint.
  In  scrophulous   habits, it also  seems
probable, that the irritation of a joint is
much  more easily produced than in other
constitutions,; and no one can doubt, that
when once excited  in the former class of
subjects,  it is much more dangerous, and
difficult   of  removal, than in  other pa-
tients.
  The doctrine of particular white-swell-
ings, being scrophulous  diseases, is sup-
ported by many weighty reasons, the opi-
nions of the most accurate obseVvers, and
the evidence of daily experience.  Wise-
man (Book 4,  chap.  4.) calls the spina ven-
tosa a species  of scrophula, and tells us,
that infants  and children are generally
the subjects of this  disease. The disorder
is said by Severinus to be exceedingly
frequent in young  subjects.  Petrus de
Marchettis  has  observed both male and
female subjects affected  with  what are
called strumous diseases of the joints, as
late as the age of five and  twenty ; but
not afterwards, unless they  had suffered
from scrophula before that period of life,
and had not been completely cured.  R.
Lowerus also maintains a similar opinion.
Even   though a  few persons may have
scrophulous diseases of the joints, for the
first time, after the age of twenty-five, this
occurrence, like the first attack of scro-
phula after this period, must be consider-
ed as extremely uncommon.
  Another argument, in favour of the doc-
trine, which sets down particular kinds of
white-swellings as scrophulous, is founded
on the hereditary nature of such forms of
disease.
  Numerous continental surgeons, parti-
cularly Petit and Brambilla,  have noticed
how very subject the English are both to
scrophula  and  white-swellings  of the
joints.   We every day see, that yoong per-
sons afflicted with the present disease, are
generally  manifestly scrophulous, or have
once been  so.  Very often enlarged ly m-' 
160
JOINTS.
phatic glands in the neck denote this fatal
peculiarity of constitution;  very often the
parents  are known to have  descended
from parents who had strumous disorders.
(Crowther.)
  Besides the general emblems of a scro-
phulous constitution, which we shall no-
tice in tiie article Scrophula, we may often
observe a shining,  coagulated, flaky sub-
stance,  like white  of egg,  blended with
the contents of such abscesses as occur in
the progress ofthe disease.  This kind of
matter  is almost peculiar to scrophulous
abscesses, and forms another argument in
support of  the foregoing observations re-
lative to the share, which  scrophula fre-
quently has in the origin and  course of
many white-swellings.

    TREATMENT OF WHITE-SWELLINGS.

  In practice we meet with  all these cases
both scrophulous and rheumatic ones, in
two very opposite states; sometimes the
diseased joint is at the same time affected
with a degree of acute inflammation; in
other instances, the malady is entirely
chronic.
  The imprudence of patients  in walking
about, and disturbing the  diseased part,
is very  often the occasion of a degree of
acute inflammation, which  is denoted by
the tenderness of the joint when handled
by the surgeon, and also by the  integu-
ments feeling hotter  than those of the
healthy knee.  Acute inflammation is it-
self a frequent  forerunner of the most in-
veterate diseases of the joints.
  When such state exists, there can be no
doubt, that topical bleeding, and cold sa-
turnine  lotions, are means  which may be
eminently serviceable. The  antiphlogistic
regimen is now strongly indicated.  Cool-
ing purges of the saline kind should  also
be exhibited.  Blood maybe taken from
the  diseased part, either  by  means of
leeches  or cupping.  Mr. Latta gives the
preference to the Tatter method, whenever
it can be employed; and he very properly
remarks, that little advantages can be ex-
pected from topical bleeding of any kind,
unless the quantity of  blood taken away
be considerable.  Ten  or twelve  ounces
by cupping should be taken away at a
time, and the operation should be repeated
at proper intervals, till the tenderness and
heat of the skin have  entirely subsided
When leeches are used, the number ought
to be considerable, and Mr. Latta recom-
mends the  application  of at least sixteen
or twenty.  (System of Surgery, Vol.  I.
chap. 6.)
  When the diseased joint is very tense,
painful, and inflamed, the pressure  of
cupping glasses is too  irritating.
  Though such antiphlogistic means  are
judiciously put into practice,  when acute
inflammation  prevails; yet such  practi.
tioners as lose weeks and  months in the
adoption of  this  treatment,  are  highly
censurable.   While  the skin  is hot  and
tender,  while the joint is affected with
very acute and general pain,  and  while
the  patient is indisposed  with the usual
symptoms  of inflammatory fever, great
benefit may be rationally  expected from
the  above  plan.   When,  however,  this
stage of the disorder is over, and the dis-
ease is  a truly chronic one, the  method
becomes ridiculously inert, and, as pre-
venting the employment of a proper plan
of treatment  may be considered, in a cer-
tain degree,  conducive to the  augmenta-
tion of a most cruel  distemper.  Every
conscientious surgeon  would  shudder to
be guilty of recommending inactive mea-
sures to  oppose an  inveterate  disease,
were he only to have a proper  idea of  the
vast number  of lives and limbs which  are
continually falling sacrifices to such  slo-
venly practice.
  Although I am not fortunate enough to
coincide with Mr. Crowther on this point,
who employs bleeding for a much longer
time, than seems tome advantageous,yet
I am content to let general experience de-
termine which of us is right.  There  are
some cases, I know, (and one  such I  had
lately under my care in private practice,)
which require topical bleeding and cold
applications  much  longer than  others.
There are other instances,  which will
never bear the irritation of blisters  and
the savine cerate, but are exasperated by
this treatment.  Such, however,  is  not
the nature ofthe disease in general, when
the acute inflammation, accidentally pre-
sent, has been removed by antiphlogistic
means.   Having  seen  numerous white-
swellings in  St. Bartholomew's Hospital,
invariably unretarded by a  long recourse
to that universal panacea, white wash, aided
by topical bleeding, I must feel satisfied
that the censures I have passed on delay-
ing the application  of perpetual blisters,
or  issues, are not altogether unfounded.
It is curious, that, after criticising my ad-
vice  not to  lose weeks and  months in
trusting to such treatment, when the acute
symptoms have  ceased,  Mr. Crowther
should remark; " If Mr.  Cooper means
by really efficacious measures, the  appli-
cation of blistering plaster, and dressing
the surface,  after the cuticle  is removed,
with the savine cerate, or establishing
caustic issues on each side of the diseased
joint, I congratulate myself, as having been
the means of ascertaining the salutary effect
of this treatment ! /" P. 63.
  Some other passages of my works are 
JOINTS.
161
noticed  by this  unfortunate critic, with
similar inconsistency, as  I, shall take fu-
ture opportunities of explaining.
  ft is quite unnecessary to expatiate fur-
ther on  the mode of treating white-swel-
lings complicated  with  acute inflamma-
tion.  The most eligible pLn of arresting
the morbid  process in the hpnes, liga-
ments,  cartilages,  and  soft parts  sur-
rounding the articulation, and the  most
successful method of lessening the chronic
enlargement of the joint, are subjects now
demanding our earnest investigation.
  The works of  Hippocrates, Celsus,
Rhazcs, Hieron, Fabricii*t^ &c. compared
with modern  surgical books, Will soon
convince us, that the practice of the an-
cients, in  the  treatment  of diseased en-
larged joints,  does not much differ  from
the plan now  pursued by the best modern
9urgeons.  Mr. Crowther remarks, that
the ancients used local and general blood-
letting,  the actual and potential  cautery,
with vesicating and  stimulating applica-
tions  to the  skin.  They further  main-
tained,  that  sores,  produced  by  these
means, should have their discharge pro-
moted, and continued for a considerable
length of  time.
  Topical applications,  consisting  of
strong astringents of the mineral and ve-
getable  kingdom, suffice for the cure of
some mild descriptions of white-swellings.
A decoction of oak bark, containing alum,
is what is  recommended  for this purpose
by Mr. Russell.
   My own experience will not allow me
to say much in favour of electricity, as an
application for the  relief of white-swel-
lings.  Upon the whole, 1 must rank elec-
tricity  among inactive  measures;  for,
though, in a few cases, it has appeared to
do good;  in others  it has done harm, by
making the disease  more irritable and
rapid in its progress; while in most in-
stances, its eff'ects have been so  insignifi-
cant,  as to make it difficult  to decide,
whether they were of a favourable or an
unfavourable nature.
   " If the tumour is quite indolent, (says
Richerand) the application of galvanism
may  be proposed.;  it  is  not,  however,
exempt from  danger, and on one occa-
sion,  where I employed  it, lancinating
  Eains  and swelling  of the joint were
  rought on by it."  (Nosographie Chirur-
fieale, torn. 3. p. 174, Edit. 2.)
   Cases occur, in which a lotion composed
of sea-water  is  productive of benefit.   I
mean to  say, that this  application fre-
quently diminishes the enlargement of the
joint; but it hardly  ever accomplishes a
perfect cure.
   The conjoined operation of sea-air and
Bfia-bathing  has  undoubtedly  a  most
     Vol. If.
powerful influence over scrophulous dis-
eases of the joints, as well as most other
strumous disorders; but  the  application
of sea-water alone, in the form of a lotion,
cannot be greatly praised, because it pre-'
vents the surgeon from having recourse to
a better plan of treatment. Even the trial
of sea-air and bathing unitedly can only
be recommended as an auxiliary plan, to
be adopted  in  conjunction with  other
more certainly efficacious measures.
  Poultices, made of sea-weeds, deserve
the  same kind of praise as has been given
to the sea-water lotion.
  Every one is well acquainted with the
efficacy of friction in exciting the action of
the  absorbents.  To this principle we are
to impute the great benefit, which  arises
from what is termed, dry nibbing, in cases
of white-swellings.  This kind of friction
is performed  by the mere hands of an at-
tendant, without using at the same time
any kind of liniment, or other application
whatsoever, and the rubbing is continued
for  several  hours every day.  At Oxford,
many poor persons earn their livelihood
by devoting themselves to this species, of
labour,  for which they are paid a stipu-
lated sum per hour.
  1 look upon all  mere emollient applica-
tions, such as fomentations and poultices,
as quite destitute of real efficacy, and,
though they serve to amuse the patient,
they ought not to be recommended.  That
surgeon, who merely strives to please his
patient's fancy, without  doing any  real
good to him, in regard to his  affliction,
may be considered as doing harm, because
the semblance of something  being done
too often hinders other really  useful steps
from being pursued.  The  French  sur-
geons  are  particularly   liberal  in the
praises which they bestow on such" warm
emollient remedies, as poultices, steam of
hot water, fomentations,  &c.  and they
adduce instances of white-swellings Lsing
cured iu this manner.  But, whoever has
had opportunities,  of observing  the in-
veterate nature  of the  disease  in this
country, will hardly  be  inclined  to re-
commend the, imitation of French prac-
tice.
  The only method of treatment, which
my own  personal experience enables me!
strongly to recommend, consists in keeping
up  a discharge from the surface  of the
diseased joint.  1'he opportunities which
I have  had  of observing the  effects  of
blisters, and caustic issues, rather incline
me, however, to prefer the former to the
latter.  I have  seen great good derived
from both; but more from blisters,  than
the other kind of issue.  There  are in-
stances in which I should  employ vesi-
 cating applications; there are others in
     X 
162
JOINTS.
which I should prefer making an eschar
with caustic.  I have seen many instances
in  which  the  application of a  blister
could  never be endured, in consequence
of  the general  inflammatory  affection,
which it occasioned throughout  the dis-
eased joint
  The  blister - should always be  large.
Many  surgeons, instead of following Mr.
Crowther's plan,  prefer  blistering  first
one side of the joint, and then the other
alternately, for a  considerable length  of
time.  " Blisters,  (says  Mr  Latta)  may
be put upon each side of the patella, and
ought to be of such a size and shape,  as
to cover the whole ofthe swelling,  on the
inside, from the hinder part of the joint,
at the edge of the  hollow of the thigh,  to
the edge of the patella, over the  whole
extent of the swelling above  and below.
As  soon as  the blister is  taken off from
one side, it ought to be  applied  to the
other, and thus repeated alternately, until
both swelling and pain be completely re-
moved.  When this is the case, the pa-
tient ought to be directed to rub the joint
well with a liniment, composed of half
an  ounce  of  camphor, dissolved in two
ounces of oil, with the addition of half an
ounce  of spir. sal-ammon. caust.  or, as  it
is now  called, aqua ammoniac.  This  is
to be used  three times a day; and in this
way, (continues Mr. Latta) 1 have success-
fully  treated many cases of white-swel-
lings."  (Syst. of Surgery,  Vol. 1, chap. 6.)
  In the beginning,  caustic  issues are
even more  painful,  than  blisters;  but
they afterwards become more  like indo-
lent sores, and are more easily kept open,
for  a length of time, than blisters.  Such
issues  are commonly  made on each side
of the  diseased joint, and of about the
size of a  half-crown.  The manner of
making the eschars, and  keeping  those
issues open, is explained,  in  the article
Issue.
  The question has been contested, among
surgical writers  and  practitioners, whe-
ther blisters and issues produce benefit,
upon the principle of counter-irritation,
or in consequence of the discharge, which
they occasion.  They  probably  operate
efficaciously in both ways; for there  is
no doubt, that mere rubefacients possess
the power of rousing the action of the
absorbents, and they also may modify the
vascular action of diseased parts.  These
applications can  obviously only act upon
the  principle  of  counter-irritation, and,
they have  not  been here recommended
particularly for white-swellings, because,
it seems to me, that whenever some good
might  be derived from their employment,
much  more benefit could  always  be ob-
tained from  blisters   and issues.   This
sentiment is confirmed by experience, and
we must, therefore, impute a  great de-
gree of efficacy to the maintenance of a
purulent discharge from the vicinity of
the diseased part.
   We have noticed the efficacy of friction,
in exciting the action of the' absorbents,
by which the  thickened state  of parts,
around the affected joints,  may be consi-
derably lessened, and, on this  principle,
the  utility  of dry-rubbing-arises.   We
have  now  to  notice the method of  pro-
ducing the same effect by pressure, a plan,
which vet  seems to merit a more  exten-
sive trial.   1  liave seen in St. Bartholo-
mew's Hospital,  a few  cases,  in  which
the swelling of the joints was  most ma-
terially  diminished,   by encircling the
morbid articulations  with  strips  of ad-
hesive  plaster, applied with  moderatr
tightness.
   A somewhat similar plan, though its
modus operandi  is differently accounted
for, appears also to  have  been tried in
France.  " J'ai dans  quelques occasions
(says Richerand) obtenu les plus grands
avantages de  I'appli cation d'un taffetas
cire autour de  rarticulation  tumefiee.
On coupe  un  morceau de  cette etoffe,
assez large pour envelopper la totalite de
la tumeur ; on enduit les  bords d'une
gomme dissoute dans la vinaigre, et sus-
ceptible de le  faire adherer ihtimement a
la peau; on l'applique  ensuite de  ma-
niere que tout l'acces soit inderdit a l'air
entre lui et les tegumens.  Lorsqu'au bout
de quelques jours on leve cet appareil, on
trouve la peau humide, ramollie par  I'hu-
meur de la transpiration  condensee en
goutelettes  a  la  surface  inteneure du
taffetas.  Dans ce procede, on etablit un
espece de bain de vapeur autonr de l'ar-
ticulation malade.   (Nosographie Chirur-
gicale, Tom. 3, p. 175, Edit. 2.)
   My  particular friend,  Mr.   Clement
Wilson Cruttwell. of Bath, sent me, some
time ago, a very excellent case, illustra-
tive of the efficacy of treatment by pres-
sure.   He  remarks, that,  " After  cup-
ping the part,  and endeavouring to quiet
the inflammation, I used  blisters;  but
they excited such  intolerable  pain,  and
produced so great a degree of swelling
and  inflammation, that I was  under the
necessity of healing  them  immediately.  ,
After two months strict  confinement to
bed, and the use of leeches and refrige-
rant  washes,   the  infiamination  having
again  subsided,  and the pain  being re-
moved, I again  ventured to  apply one
small blister, and again a similar attack
of pain, swelling, and inflammation, was
produced.   The joint  became  distended
with fluid, of  which it  had always con-
tained a large  quantity, and the  irrita- 
JOINTS
163
tim  of tlie  constitution was excessive.
By the libera) use of opium, I once more
succeeded  in quieting the  disturbance,
and, convinced of  the  hazard  of using
blisters in such a subject, I applied  mo-
derate pressure, by means of a roller, to-
gether with a  wash, containing a large
proportion of spirit, in order to keep up
a constant evaporation.  The skin, which
was before much inflamed, and hard, has
become natural and flaccid, the pain has
ceased, the swelling has diminished, and
I have every prospect of  effecting a cure,
with  the  preservation of tolerably  free
motion in the joint."
  Mr. Cruttwell tells me, in a late letter;
that this case got completely well, by the
treatment with pressure,  and has remain-
ed so for upwards of six months, under
full and fiee exercise.
  This example clearly  evinces  the im-
propriety of using blisters in certain con-
stitutions.  In some remarks, annexed to
the above case, Mr. Cruttwell expresses
his conviction, that absolute rest,  cold
applications,  and pressure, would  suc-
ceed in very many cases, without local
counter-irritation.   Pressure,  he adds,
succeeds best, when fluid is effused, and
the disease is  indolent; but,  he is  con-
vinced that it may be used with advantage
in later stages, when abscesses have form-
ed, and sinuses already exist.  Mr. Crutt-
well,  with his usual accuracy of observa-
tion,  next reminds me, how very service-
able continued pressure is to the scrophu-
lous finger-joints of children.
  From what has been stated, I am firm-
ly of opinion, that all  impartial practi-
tioners will be disposed to give pressure
a more extensive trial, as a means of re-
lieving a disease which too frequently foils
every effort of the most skilful surgeon.
  We have noticed, that when the knee
is affected, there is a great tendency in
the limb to become  permanently bent. It
might undoubtedly be very judicious to
op|>ose the  occurrence of this  position,
by  means  of splints, which would  also
serve to prevent all  motion of tiie diseased
joint, an object of the very highest  im-
portance.   Were  the disease  to end in
anchylosis, the advantage of having the
limb in a state of extension need scarcely
be mentioned.
  Numerous diseased joints are undoubt-
edly connected with a kind of  constitu-
tion, called scrophulous.  Hence, it seems
rational to combine, with the local treat-
ment, the  employment of such  internal
remedies, as have been known to do good
in other  scrophulous diseases.   Hectic
symptoms are those, which we commonly
have  to palliate in these cases.  When
the appetite is impaired, and the stomach
will bear bark, this  medicine should  be
given  with  the  aromatic  confection.
Above all internal remedies, opium claims
tlie highest recommendation, as it at once
tends to keep off and relieve a debilitat-
ing diarrhcea, which  too frequently pre-
vails, at  the same time that it  alleviates
pain, and procures sleep.  The objection,
made against  its   exhibition,  on  the
ground  that  it  increases perspiration,
seems exceedingly frivolous,  when  the
above important  benefits are taken into
consideration-
  Too often, however,  the terrible dis-
ease of which we are now treating baffles
all  human skill  and judgment, and the
unhappy patient's health having declined
to the lowest state,  he  is necessitated to
submit to amputation, as the  only chance
of preserving life.  It has been explained
in the article Amputation that the condi-
tion  of the patient's health,  and not of
the  diseased joint,  can form  the only
solid reason tor recurring to the severe
operation of removing  the limb.  If the
patient's constitution be equal to a longer
struggle, no man can  pronounce,  that
every prospect of saving the limb is at an
end.  Many diseased joints,  apparently
in the most hopeless  condition, frequently
take  a  favourable turn, and,  after all,
allow the limb to be saved.  The state of
tlie health  is the chief consideration, in
forming a judgment respecting the pro-
priety of amputation.
  The proposal  of cutting out  diseased
joints has been considered in the article
Amputation.

        DISEASE OF THE HIP-JOINT.

  This complaint is very analogous in its
nature to the white-swelling of other ar-
ticulations.  In  the  same  way, as  the
latter disorder, it seems probable that tiie
disease ofthe hip has its varieties, some
of which may  be connected with scro-
phula, while others cannot be suspected
to have  any concern  with a strumous ha-
bit.   The "present complaint is most fre-
quently seen attacking children under the
age of" fourteen; but, image, no sex, no
rank, nor  condition of life  is exempt
from  the possibility of being afflicted, so
that though children form a large propor-
tion  of those subjects,  who are attacked;
yet the number of adults, and even of old
persons,  is cons idem ble.
  The approach  of  the disease of  the
hip-joint is much more insidious, than
that  of a  white-swelling.  Severe pains
generally precede  the latter  affection;
but, the only forerunner of the former  is
frequently  a slight weakness,  and limping
of  the  affected  limb.    These trivial 
164
JOINTS.
symptoms are very often  not  sufficiently
urgent to excite much notice, and, when
observed by  superficial practitioners, are
commonly neither understood, nor treated
according to the dictates of surgical sci-
ence.  As  there  is, also, very often an
uneasiness in  tlie knee, when the hip is
affected, careless practitioners frequently
mistake the seat of disease,  and I  have
many  times  seen patients, on  their en-
trance into an hospital, having a poultice
on their knee, vhiie the  wrong state of
tlie hip was not at all suspected.
  This mistake is extremely detrimental
to the patient, not on account of any bad
effect, resulting  from ,the applications so
applied ; but, because  it is  only in the
incipient period of the complaint, that a
favourable  prognosis can be  made.  In
this stage of  the  disease,  mere rest and
repeated topical  bleeding, will  do  more
good in the  course of a  fortnight, than
large painful  issues will afterwards  gene-
rally accomplish  in the long space of a
twelvemonth.
  The  symptoms of the  disease of  the
hip-joint, when  only looked for in  the
situation of  that articulation,  are  not
very  obvious  to  die  surgical  examiner.
Though the attention of  the surgeon is,
in some instances, soon called to the right
situation of the disease, by the existence
of a fixed  pain behind  the trochanter
major; yet, it is too often the  case, that
mere pain about  an articulation, entirely
destitute  of  visible enlargement* and ex-
ternal alteration  of colour, is  quite dis-
regarded, as a complaint of no importance
iu young  subjects, and as a  mere  rheu-
matic, or gouty  affection, in adults.  Pa-
tients frequently complain of most of their
painful sensaions being in the groin,  and
all accurate  observers  have-  remarked,
that, in  the  hip-disease, the pain is  not
confined to the  real seat of disease, but
shoots down the limb, in the course  ofthe
vastus externus  muscle to the knee.
   Tue early symptoms of disease  in the
hip-joint are only strongly delineated to
such practitioners, as have acquired  the
necessary information relative to t'.iis part
of surgery, from careful study, and ex-
tensive experience.
   We shall next trace those characters of
the  present  disease, which  serve  to de-
note its existence.
   It is a curious circumstance,  that when
the  functions of a limb are obstructed by
disease, the bulk of the member generally
diminishes, and  the muscles become ema-
ciated.  Nearly as soon as the least  de-
gree of lameness can  be perceived, the
leg  and thigh have actually wasted,  and
their circumlereuce has become less.
   If the  surgeon make pressure on the
front ofthe joint, a little on the outside of
the femoral artery, after it has descended
below the os pubis, great pains will be
experienced.
  The limping of the patient is  a clear
proof that something about the limb is
wrong, and, if  such  limping cannot be<
imputed  to diseased vertebrae, or some
recent accident, and if,  at the same time,
tiie above-mentioned emaciation of  the
limb exists, there is a great cause to sus-
pect,  that the hip is diseased, particular-
ly, when the pain is augmented by press-
ing the front of the acetabulum.        ,
   Diseased vertebrae,  perhaps,  always
produce a paralytic affection of both legs
at once, and  they  do not cause painiul
sensations about the knee, as the hip-dis-
ease does.
  The increased length of the  limb, a
symptom  that has been noticed  by all
practitioners since De  Haen,  is a  very
remarkable and curious occurrence, in
the early  stage of the present  disease.
1'his symptom  is easily detected by a com-
parison of' the condyles of the os femoris,
tlie trochanter  major, and malleoli, ofthe
diseased  limb, with  those  parts of the
opposite  member,  taking  care that the
patient's  pelvis is evenly  situated.  The
thing is the more striking,  as the increas-
ed length of the member is frequently as
much  as  four inches.  The  rationale of,
this fact, John Hunter  used to explain
by the  diseased  side of  the pelvis be-
coming lower,  than the other.  ( Crowther,
p. 266.)
   The same  thing was noticed by Fal-
coner, before Mr. Crowther. (On Jschias,
p. 9.)
   An  appearance of  elongation  of the
 limb  is  not exclusively confined to the
early^stage of the  morbus  coxarius; it
 may  attend other cases.   1  remember
 seeing in one of  the wards of St, Bar-
tholomew's Hospital, a little girl, with  a
diseased  knee, whose  pelvis  was consi-
derably distorted in this manner, so that
the limb ofthe same side appeared much
elongated. .  Her  hip-joint  was  quite
 sound.  This case was pointed out to Mr.
 Lawrence and myself by Mr. Cother, of
 Gloucester.
   Mr.  Ford  has very accurately  called
 tlie  attention  of surgeons  to the altera-
 tion, with respect to the  natural fulness
 and convexity of the nates, that part ap-
 pearing  flattened,  which is usually  most
 prominent.  The  gluteus  magnus be-
 comes emaciated, and its edge no longer
 forms so bold a line, as it naturally does
 at the upper and back part of the thigh,
 in the sound state ofthe limb.
   Though there may be more pain about
 the knee, than tfle hip, at some periods 
JOINTS.
165
of tlie malady  in its incipient state, yet,
the former articulation may be bent and
eitended, without any increase of unea-
siness ;  but,  the  os  femoris cannot  be
moved about, without putting the patient
to immense torture.
  The patient soon gets into the habit of
bearing the  weight of  his body chiefly
upon the opposite limb,  while  tiie thigh
of the affected  side is bent a little for-
ward,  that  tiie ground  may  only  be
partially  touched  with  the foot.  This
position  is found  to be  the most com-
fortable,  and every attempt to extend the
limb occasions an increase of pain.
   This is the first stage ofthe disease,' or
the one, wliicli is unaccompanied with
suppuration.                    ,
   The symptoms which precede the form-
ation of  pus, vary in different cases,  ac-
cording as  there is acute, or chronic in-
flammation present.   When tiie diseased
joint is affected with acute inflammation,
the surrounding parts become tense and
extremely  painful; the  skin is even red-
dish;  and  symptoms  of inflammatory
fever prevad.  When the severity of  the
pain  abates, a  swelling occurs in  the
vicinity of the joint, and a pointing quick-
ly follows.
   When the abscess is a chronic one,
there is no particular increase of pain pre-
ceding the collection of matter.
   Startings and catchings during sleep
are said  to be among the most certain
signs  of the formation of matter, in this
stage of the disease.
   We have noticed the lengthened state
of the limb, in the first periods of tiie hip-
disease.  This  condition is not of very
long duration, and% sooner*, or later suc-
ceeded by a shortening of the affected
member.  The  toes are  turned inwards;
the great trochanter  is approximated to
the crista of tlie os ilium; the leg is  in a
state of flexion; and all the symptom?
of a luxation of the thigh upwards  and
outwards,  may be  observed, 'the head of
the  bone indeed  being  actually  drawn
into the external iliac fossa, and carried
betwixt  the os  innominatum and gluteus
minimus, which is raised up by it.  (See
hk/terand's  Nosographie   Cldrurgicale,
Tom. 3, p 171,  172,  Edit. 2.)
   When the  retraction  is  very consider.
able, it arises from nothing less,  than an
actual dislocation of  the head  of  the
thigh-bone, in  consequence  of the  de-
struction of the  cartilages,  ligaments,
and  articular  cavity.    This  retraction
sometimes comes on long before any sup-
puration takes  place.  The head of  the
bone is  sometimes dislocated,  and  the
disease terminates in anchylosis, without
any absciss whatever.
  It is worthy of particalar notice, that
the head of "the bone is always luxated
upwards and outwards ; and the only ex-
ception to this observation, upon record, is
a case related  by the celebrated Italian
practitioner Cocchi, in which a spontane-
ous dislocation of the thigh-bone, as it is
termed,  happened »upwards,  forwards,
and a little inwards.  (See Leveilies. Nou-
velle Doctrine Chirurgicale, Tom. 2,p- 595.)
On a egalement vu la tete du femur luxee
en dedans et en bas, et placee sur le trou
obturateur, mais ce mode de deplacemeut
consecutif,   dans lequel le roembre  est
alonge,  est  infiniment rare.  (Richerand,
Nosographie Chirttrgicule, Tom. 3,p. 172.)
  The hip-disease generally induces hec-
tic symptoms, after it has existed a cer-
tain tune.  In some subjects, such symp-
toms  soon come on; in others, the health
remains  unaffected a  very considerable
time.
  When abscesses of the  above descrip-
tion burst,  they continue, in general, to
emit  an unhealthy thin kind  of matter
for a long time afterwards.
   With respect  to the morbid anatomy of
tlie disease  in its  incipient state, little is
known.   Two dissections  related by Mr.
Ford are, perhaps, the only ones throwing
light upon this point.   In  one,  there was
a tea-spoonful of matter in the cavity of
the hip-joint.  The  head  of the thigh-
bone  was a  httle inflamed, the capsular
ligament a little thickened,  and the liga-
mc-ntum teres united in its natural way to
the acetabulum.  The cartilage lining the
cotyloid cavity was eroded in  one place,
with  a  small aperture,  through which a
probe might be passed, underneath  the
cartilage, into the internal surface of  the
os pubis, on one side, and, on the other,
into the os  ischii; the opposite, or  ex-
ternal part  of the os  innominatum shew-
ing more appearance of disease, than  the
cotyloid cavity.  In the other  instance,
the disease  was more advanced.  These
examples  are  important,  inasmuch  as
they prove that  the hip-complaint prima-
rily  affects  the cartilages, ligaments, and
bones, and not the surrounding soft parts
as De Haen, and some others would ie^d.
one to believe.
   As the disorder advances,  the portions
of the os ischium, os ilium, and os pubis,
composing the acetabulum, together with
tiie   investing   cartilage,  and synovial
gland, are destroyed.  The cartilage  co-
vering  the  head of tlie os  femoris,  the
ligamehtum teres, and  capsule  of  the
joint, suffer tlie same fate, anil caries  fre-
quently affects not only the adjacent parts
of the os innoniinata, but also the head
and neck of the thigh-boue.   The bonev
of the pelvis, however, are always mote 
166
JOINTS.
 diseased  than  the thigh-bone,  a  fact,
 which  displays  the aosurdity  of ever
 thinking  of  amputation  in these cases-
 Mr. For. observes,  "In every case  of
 disease of ihe hip-joint, which has termi-
 nated fatally, I  have remarked,  that the
 os tnnominatu n has  been affected by the
 caries  in a more extensive degree, than
 tlie thigh-bone  itself."  (Observations  on
 the Disease of the Hip-joint, p. 107.)
   Sometimes, however, the head and neck
 of the thigh-bone are annihilated, as well
 as the  acetabulum.
   External violence; laying down on the
 damp  ground in summer time; and  all
 kinds of exposure, to damp and cold; are
 the causes to which the disease may some-
 times be referred.  Scrophula, no doubt,
 has, frequently,  some  concern in  tlie
 origin  of the malady;  but, oftentimes,
 no rational cause of tlie complaint can be
 assigned.

   THEATMBNT OF THE DISEASE OF THE HIF-
                 JOINT.

   Hippocrates,  Celsus,  Cxlius  Aurelia-
 nus, &c. convince us in their writings,
 that the ancients treated the present dis-
 ease much, in the same way  as  the mo-
 derns*.   Forming an eschar, and  keeping
 the sore open; topical bleeding; cupping;
 fomenting the part, &c. were all proceed-
 ings adopted in the  earliest periods of
 surgery.  Drs.  Charlton,  Oliver, and
 Falconer,  have extolled Bath water, as a
 most efficacious application to diseased
 hip-joints,  previous  to the suppurative
 stage.   However, had not their accounts
 been exaggerated, all patients of this kind
 would  long ago have flocked to Bath, and
 the surgeons  in other  places would never
 have had further  occasion  to adopt  a
 more painful mode of treatment.
   The plan pursued at Bath, is to put the
 patient in a  warm  bath, two  or three
 times a week, for fifteen or twenty.five
 minutes.
   In the early period of the disease, en-
 tire rest, the  application of fomentations,
 and the employment of topical bleeding,
 particularly cupping, are highly proper.
 Such practice, also, is invariably judici-
 ous, whenever the case is attended with
 symptoms of  acute inflammation.  When
 the fomentations are  not applied,  the
 fotio aquae lithargyri acetati may  be used.
   This method of treatment ought never
 to be employed unless there are manifest
 marks  of active inflammation  present.
 When no such state exists, this plan can
 only be regarded as preventing the adop-
 tion of a more efficacious one,  and, there-
, fore, censurable.
   As far as morbid anatomy can inform
 us, the hip-disease consists  of tlie same
 alteration  of the bones, ligaments,  and
 cartilages, as takes place in  tiie majority
 of white-swellings..  Hence, both diseases
 should be treated on the same principles.
 Quibus diulurno dolore, says  Hippocrates,
 ischiadico vexatis coxaecccidit, Usfemur con-
 tabescit et claudicant, nisi urantur. Form ing
 an eschar, or issue, is the most efficacious
 plan of treating the disease  even now
 known.
   A caustic issue seems to be more bene-
 ficial than a blister, in cases of diseased
 hips.  The depression,  just  before  and
 below  the trochanter major  is the  situa-
 tion, in which surgeons usually make  the
 issue,  and the size of the eschar should
 be nearly as  large  as  a crown-piece.  It
 is, in general, necessary to keep the issue
 open a very long time.  When the thigh-
 bone is dislocated, the case mostly ends
 in anchylosis.

   FBNOIJS HJBMATODES OF THE  HIP-JOINT.

   Mr.  Bums,  in the second volume of his
 " Dissertations on inflammation," p. 311,
 has recorded a  remarkable  instance,  in
 whj.ch  this joint was  affected  with that
 intractable and fatal distemper, the fun-
 gus hasmatodes.  The  case was at first
 supposed to be the disease, of which  we
 have just been speaking in the preceding
 section.  The limb seemed to be elongat-
 ed, and  issues were employed, without
 any material benefit.   The upper part of
 the thigh swelled, while the lower wasted
 away.  The patient lost his appetite, had
 a quick pulse, and passed sleepless nights.
 The part was rubbed with anodyne bal-
 sam, and laudanum given every night;
 but, these means were only productive of
 temporary benefit.  After some months, a
 difficulty of making water came on, which
 ended  in a  complete retention.  It being
 found  impracticable  to  introduce a  ca-
 theter, and a  large elastic tumour, sup-
 posed'to be the distended bladder, being
 felt within the rectum, a trocar was push-
 ed into  the  swelling.   A good deal of
 bloody fluid was thus discharged.  After-
 wards  a considerable quantity of  high-
 coloured fetid urine continued to escape
 from the urethra.  In about a week from
 this operation, the patient died.
   On  dissection,  Mr.  Burns  found  the
 hip-joint completely surrounded with a
 soft matter, resembling brain, inclosed in
 thin cells, and here and there other cavi-
 ties, full of thin bloody water, presented
 themselves.  The acetabulum and head
 of the os femoris were both carious.  The
muscles were  quite pale, and almost like
boiled  liver, having lost their fibrous ap-
pearance.   The same  kind of substance 
KAL
KNE
16?
was found in the pelvis, and most of the
inside  of the  affected bones carious.
Large  cells, containing  bloody  water,
were  observed in the diseased substance,
and it was into one of such cavities that
the trocar had entered  when the attempt
was made to tap the bladder.  See " Trea-
tise on the Diseases of the Joints" being the
obsenuti oris for which the prize for 1806 was
adjudged by the Royal College of Surgeons,
I/mdon. Ford's Observations on the Disease
of the Hip-Joint are particularly excellent.
See also  Crowtlier on White-Swelling, &c.
Edit. 2, 1808.  Latta's System of Surgery.
B. BelPs  Surgery.  Falconer  on  Ischias.
Burns  on Inflammation,  Vol.  2,  p.  311.
The authors quoted throughout  this article,
both ancient and modern, may all be consulted
with advantage.
  JUGULAR.  VEIN,  how to bleed in.
See Bleeding.
K.
    KALI  JERATUM.—v,.  Kali  praepa-
     rati 3ss. Aq. distillate gv. Ammon.
praeparatae 3J.  Dissolve the kali  in a
water-bath ;   add  the  ammonia 1  and,
when the effervescence has ceased, let the
fluid crystallize.  Two  drams  are given
as a litliOHtriptic, in  a  pint  of distilled
water, twice a day, at St. Bartholomew's
Hospital. (Pharmacopeia Chirurg.)
  KALI  ARSENICATUM— *. Arseni-
ci albi, Nitri  purif., sing.  ^j.  Cruci-
bulo amplo igne  candenti injice nitrum,
et liquefacto adde gradatim arsenicum  in
frustulis donee vapores  nitrosi  oriri  ces-
saverint.  Solve materiam  in aquae  dis-
tillate  libris quatuor, et  post idoneam
evaporationem sepone ut fiant crystalli.
  These  crystals may  be  given in the
dose of one tenth of a grain, thrice a day.
(Pharm.  Sancti   Barthol. 1799.)  Justa-
mond strongly recommended  the internal
exhibition of arsenic  in cases of cancer.
See Cancer'.
  KALI  PURUM.—This  is one of the
most useful caustics for  destroying  fun-
guses, making issues, in cases of diseased
vertebrae, white swellings, &c.; and  it is
recommended  to be used in  a particular
manner, by Mr. Whately, for the cure of
strictures in the urethra. When surgeons
prefer  opening buboes, or any other ab-
scesses, with  caustic, the kali piirum is
very commonly employed.   When  sur-
geons used to care hydroceles, by destroy-
ing a  part of the scrotum and  tunica
vaginalis with  caustic, the kali  purum,
either  alone, or mixed with  quicklime,
was made use of.   (See particularly  Ver-
tebrx,  Diseased;  Urethra, Strictures of,
Uc.)
  KALI SULPHURATUM. Two drams
of this, dissolved in a pint of lime  or dis-
tilled water, make an excellent lotion for
the cure of the tinea capitis. Many other
cutaneous  affections  yield, also,  to  the
same remedy.  When arsenic  has been
swallowed as a poison, it is best to give
first, twenty grains of zincum vitriola-
tum, as an emetic the quickest in its ope-
ration ; and, after keeping up the vomit-
ing by  drinking  warm water, and, what
is better, sweet oil, it is recommended to
make the patient drink as much  as  pos-
sible of a solution of the kali  suj.phura-
tum, the sulphur of  which is  known to
blunt the activity ofthe mineral.
  KNEE,  DISEASES OF.  See Joints.
  KNEE-CAP, its effects in relieving the
inconveniences  resulting  from cartilagi-
nous substances in the knee. See Joints. 
168
LAB
LEU
L.
    LABIA LEPORINA. See Harelip.
        LAGOPHTHALMIA,  OR  LA-
GOPHTHALMOS. (from A*y<>5, a hare;
and «<p6xXf*.o(, an eye ) The Hare's Eye. A
disease, in which the eye Cannot be shut.
The following complaints may arise from
it; a constant weeping of the organ,  in
consequence  of the  interruption of the
alternate closure and opening of the eye-
lids,  which motions so  materially  con-
tribute to propelling the tears into the
nose; blindness  in  a  strong light,  in
consequence of the inability to  moderate
the rays,  which  fall on the eye ; on the
s-'ine account,  the sight becomes gradu-
ally very  much weakened;  incapacity
to  sleep where there is  any light; ir-
ritation, pain, and redness  of the  eye,
from this  organ being exposed to  the
extraneous substances in the atmosphere,
without the eye-lids having the power of
washing them away,  in the  natural man-
ner.
  An enlargement, or protrusion of the
whole eye, or a staphyloma, may obvious-
ly produce lagophthalmos. But, affections
of  the upper eye-lids are  the common
causes.  Heister says, he has  seen  the
complaint originate from a disease of the
lower one.  Now and then lagophthalmos
depends  on paralysis of the orbicularis
muscle.  A cicatrix,  after a wound, ulcer,
or burn,  is the most  frequent cause.
  When lagophthalmos arises from a pa-
ralytic affection  of"  the orbicularis  pal-
pebrarum, let the eye-lids be rubbed  with
the tinctura cantharidum, and  cold  wa-
ter, or the linimeirtum camphorae.  Elec-
tricity is also considered as a principal
means of cure,  (Chandler) together with
the exhibition  of bark, the use of the
shower-bath,  &c.
  When  the  affection arises from  spasm
of the levator  palpebrae superioris, elec-
tricity, a small blister on the neighbour-
ing temple, and rubbing the eye-lid and
eye-brow with the tinctura opii," are good
means.   Internal anti-spasmodic  medi-
cines may also be tried.
  When  lagophthalmos arises from the
contraction of a cicatrix, its relief is  to
be attempted  precisely on the same prin-
ciples as the ectropium. (See Ectropium.)
In some cases,  it will not  be amiss, es-
pecially at night, to  lay plasters, drawing
in contrary directions Upon each lid, and
 to assist them by a compress and bandage,
 (Chandler.)
   The inconveniences, depending on the
 eye being unable to shelter itself from the
 light, are to be  obviated by wearing a
 green shade, till the disorder is cured.
   Whoever  is acquainted with German
 and  is desirous of more  minute informa-
 tion  on this subject,  may find an excel-
 lent account of fagophthalmos  in  Rich-
 er's Anfangsgr. der Wundarzn. Band2,
 Von dem Hassenauge.  See also Chandler
 on the Diseases of*-the Eye. Chap. 2.
   LARYNGOTOMY.  (from  A«fvy{, the
 larynx ; and rtfMot, to  cut.)   The cutting
 an opening into the larynx.   (See Bron-
 chotomy.)
   LATERAL OPERATION.  One mode
 of cutting for the stone is  so termed.  (See
 Lithotomy.)
   LENS   CRYSTALLINE   OPAQUE.
 (See Cataract.)
   LENTICULAR.    (from  knticulaire,
 doubly convex.)  An instrument,  con-
 tained in every trephining case, and em-
 ployed for removing the jagged particles
 of bone from the edge of the perforation,
 made in  the cranium  with  the trephine.
 One side of its blade is convex,  the other
 concave ; and  one of  its edges is sharp.
 On the end of the blade is fixed a  little
 shallow cup, with its concavity towards
 the handle of the instrument.   This part
 serves the purposes of receiving the little
 pieces of bone, when detached, keeping
 the end of  the blade from hurting the
 dura mater, and, when applied under the
 margin of the opening, enables the ope-
 rator to  guide the edge of the instru-
 ment all  round it, with steadiness and se-
 curity.
   LEUCOMA. (from Atuxe?, white.) Leu-
 coma and albugo are  often  used synony-
 mously, to denote a white opacity of the
 cornea.   Both of  them, as Scarpa re-
' marks, are essentially different from the
 nebula of the cornea; for,  they  are not
 the  consequence  of chronic ophthalmy,
 attended with varicose veins, and an effu-
 sion of a milky serum into the texture of
 the delicate continuation of  the conjunc-
 tiva over the cornea;  but, are the result
 of violent acute ophthalmy. In this stage,
 a dense coagulating lymph is extravasat-
 ed from the arteries ;  sometimes superfi-
 cially, at other times deeply into the sub- 
L£ U                                 LIG               169
stance of the  cornea.  On other occa-
sions, tiie  disease consists of a firm cal-
lous cicatrix on this membrane, the effect
of an ulcer, or  wound, with  loss of sub-
stance.  The term albugo, strictly belongs
to the first form of the disease;  leucoma
to the last, more particularly when the
opacity occupies the  whole,  or the chief
part,  of the cornea.
  The recent albugo, remaining after the
cure of a severe acute ophthalmy, is of a
clear  milky colour;  but, when of ancient
date,  it becomes pearl-coloured.  Some
cases, which have existed a considerable
time, do not seem to have  any connexion
with the vascularity of the cornea;  for they
continue insulated  in the  middle of the
transparent portion  of this membrane,
without occasioning the least uneasiness
to the patient, the least disturbance ofthe
rest of the eye, or any attempt of the ab-
sorbents toTremove them.
  The recent  albugo, provided the orga-
nization of the cornea  be not destroyed
may generally be dispersed by the means
employed for  the relief of the  first and
second stages  of acute ophthalmy;  viz.
general and topical  blood-letting with in-
ternal antiphlogistic medicines, and topi-
cal emollients for the first; slightly  irri-
tating and  corroborant applications  for
the second.  As soon as the inflammation
has subsided, the latter should be employ-
ed ; for, by making the absorbents remove
the coagulating lymph, deposited in  the
cornea, they restore the transparency of
this membrane.
  But,  though this may often be accom-
plished in the recent state of albugo, it is
not so easy to  be done,  when the long du-
ration of the  disease has paralized  the
absorbents ofthe affected part of the cor-
nea ;  or when the deposition of  a dense
tenacious substance into its intimate tex-
ture, has subverted its organization.  In
one instance, the matter forming the al-
 bugo cannot be absorbed ; in the other, it
 leaves the cornea so much injured, after
 its absorption, that  it  continues opaque.
 (Scarpa.)
   The  recent condition  of  the  disease,
 without disorganization of the structure
 of the cornea; its  occurrence in young
 subjects, whose  absorbents  are  readily,
 roused by external  stimulants;  are  cir-
 cumstances very  favourable to the cure.
 The opacity of albugo in children, arising
 from severe ophthalmy after the small-
 pox,  and remainingrinsulated in the centre
 of the transparent cornea, very often dis-
 appears in the course of a few months,
 even  without the  interference of  art.
 Heister,  Langguth,  and  Riehter,  have
 made the  same observation.  The event
 can  only  be  imputed to the  vigorous
     Vol. II.
action of  the  lymphatics in children
and to the organisation of the cornea not
being destroyed. To promote this absorp-
tion, Scarpa has found the following col-
lyrium a most  efficacious  one:  9,.  Am-
man, muriatx. ^ij.  Cupri acetati gr. iv.
Aqux Calcis Sviij. Misce.   To be filtered,
after standing twenty-four hours.
  He praises also this ointment: £. Tutix
prxpar ^j.Aloes, s pgr ij. calomelanosgr.
ij. Adipis suillet. ^ss. Misce. And the un-
guentum ophtlialmicum of Janin.  He men-
tions the gall of the ox, sheep, pike, and
barbel, applied to the cornea, two or three
times a day, with a small hair pencil, if
too much irritation  should not be pro-
duced.  In some subjects, when the eye3
are very irritable^ and cannot bear the lat-
ter applications, Scarpa has found the od
of walnuts, when rather rancid, very bene-
ficial ; two or three drops being insinuated
into the  eye,  every two hours, for soma
months.  In others, he  has  found the
juice of the lesser centaury,  mixed with
honey, of service
  It is generally necessary to persevere
very strictly, for at least  three  or four
months, before the case  can be reckoned
incurable.
  All  the  expedients, proposed for the
inveterate  albugo or  leucoma  from a
cicatrix, consisting of scraping or  perfo-
rating the layers ofthe cornea, and  excit-
ing ulceration there, are unavailing. For,
though, the enlargement  of the cornea,
should be lessened by such means, its dia-
phanous state could not be restored;  or
should the patient perceive a ray or two of
light immediately after the operation, the
benefit would only  be transient; for, as
soon as the wound'had healed, the opacity
would recur.  The formation of an artifi-
cial ulcer might prove useful, did leucoma
depend on a mere extravasation of lymph;
but, the fact is, the disease arises from the
deposition of an opaque  substance, and
the disorganization of the textore of  the
cornea, conjointly;  in this lies the differ-
ence between albugo and leucoma.
  See Scarpa sulle Malattie  degli  Occld.
 Venezia; 1802.  Richter's Anfangsgrunde
der Wundarnz. Band 3. Essays on the Mor-
bid Anatomy of the eye, by J. Wardrop ;
Edinb. 1808: 'chap. 11.
  LIGATURE, (from ago, to bind.)   In
the article Hemorrhage, we have noticed,
that the immediate  effect of a tight liga-
ture on the  artery,  is to cut  through its
middle and  internal coats, a circumstance,
that tends very much  to promote the ad-
hesion of the opposite sides of the  vessel
to each other. Hence, the form and mode
 of applying  a  ligature to an artery should
be such as are most certain of dividing
 the above coats of the vessel,  in the most
     Y 
iro              LIN                                 -lip
favourable manner.  A broad flat ligature   or three minutes  together, morning and
does not promise  to answer this purpose   evening, on the outside and edges of the
in the best manner; because it is scarcely   e^e l.ils. (Phwm. Chirurgica.)
possible to tie it smoothlv round die arte-    ' L.1NTMKNTLM HYDRARGYRl COM-
ry, which is very  likely to be thrown into   POS1TUM.—*.  Ung hydrargyri tortio-
folds, or to be puckered bv it, and, conse-   ris,  Ad.pis  suills,  sing.  3J.  Camph.
quentlv, to  have  an irregular bruised   §ij Spirit, vinos, rectif. 31J. Aq. amnion.
wound made  in  its middle and internal   pur. 3j.—The  camphor being dissolved in
coats. (Jones.) A ligature of an irregu-   the spirit of wine, add the aq.  amnion, and
lar form is  likely to cut through these   the ointment previously blended with hogs
coats more completely at some parts than  lard   (Fhami. Sancti Barthol.)  A  truly
others; and  if it does not perfectly divide  excellent formula for all surgical cases, in
them, no adhesion can take place, and se-  which the object  is to quicken the action
condary hemorrhage will follow.  A tear  ofthe absorbents, and gently stimulate
of tying the ligature too tight may often  the surfaces of parts.  It is a capital ap-
lead to the same consequences.  These,  plication for  diminishing the  indurated
and many other impbrtant circumstances,  state of particular muscles, a peculiar af-
are noticed  in the article Hemorrhage.     fection every  now and then met with in
   Ligatures are commonly made of inkle,  practice ; and  it is particularly well calcu-
waxed together with white wax.  They  lated  for  lessening the  stiffness  and
should  be round, and very firm, so as to  chronic thickening  often noticed in the
allow being  t ied with some force, without  joints.
risk of breaking. (See Jones on Hemorrhage,     L1NTMENTUM  SAPONIS  COMPO-
p. 172.)                                S1TUM.—5,.  Sapon. giij.  Camph. |j.
   LINIMENT, (from lino, to anoint.) A  Spirit, rorismar. Ibj. Dissolve  the soap
very  soft  kind  of  ointment,  not much  in  spirit,  and then  add the camphors-
thicker than oil, and intended to be smear-  Uses the same as those of the linimentuni
ed, or rubbed on parts.                  camph.
   We  shall  only  mention  here, a few     LINIMENTUM SAPONIS CUM OPIO.
 of the most useful ones for surgical  pur-  &■  Lin. sapon.  comp.  §vj. "ilinct.  opii
poses.                                  §ij. Misce.—For  dispersing indurations
   LIN1MENTUM  AMMON1JE  FOR-  and swellings  attended  with pain, but no
TIUS.—fy.  Aq.  ammon. pur. ^j.  Olei  acute inflammation.
olivae gij. Misce.  Used for stimulating      L1NIMENTUM TEREBINTH IN &.
the surfaces of parts in which it is wished  5<-  Ung. resmae flavae 3*iv. 01. terebintlii-
to excite the  action of the absorbents.  It  nae, q s. Misce.   The celebrated applica-
is  serviceable in removing  indurations,  tion tor bums, recommended by Kentish.
 stiffness ofthe joints, "&c.                 (See Burns.)
   LIN1MENTUM  CALCIS— *.  Aqua:       LIN1MENTUM TEREBINTHlX.fi
 calcis, Olei  olivae, sing, gviij. Spirit, vinosi  V1TR10L1CUM.—$,. Olei olivae Jx. 01.
 rectificati^j. Misce.—A common applica-   terebinth,  3*iv. Acidi vitriol, ^iij. Misce.
 tion to burns and scalds.                 —Said to  be  efficacious in chronic  afl'ec-
   L1N1MENTUM CAMPHOR JE  COM-   tions of the joints, and in the removal of
 POSITCM.—%.  Camp.  ?ij.  Aq.   am-   long existing  effects of sprains and bruis-
 mon. §vj.  Spirit lavend. 3XVJ.  Sixteen   es.   (Pharrn.  Chirurgica.)
 ounces are to be distilled of  the two last     LIP, CANCER  OF.  The  lips  are
 ingredients, from a glass retort, and the   subject to  ulcers, which  put  on a very
 camphor then dissolved in the distilled   malignant aspect, although they are not in
 fluid—For bruises, sprains, rigidities of • reality malignant;  and many  of  these,
 the joints,  incipient chilblains, &c.        occurring just on the inside of these parts,
     LINIMENTUM     CAMPHORS   wjll be found  to depend on the  bad state
■jCTHEREUM.—fc. Camphorae drach. j.   of the constitution,  and the irritation and
 .fitheris une. ss. Olei viperarum  drach.   disturbance which the sores are continual-
 ij. Misce.  The camphor is  to be  dis-j ly suffering from the incessant motion of
 solved in the  aether, and the oil afterwards   the parts, and their rubbing against a pro-
incorporated  with it.                    jecting, or rough tooth.
   This formula, communicated by  Mr.     When cancer takes place, it is usually
 Ware, is adapted to those obscure aff'ec-  in the lower,  and very  seldom in the up-
 tionsof the eye,  in which it is not easy to  per lip.
 determine,  whether the imperfection of    The disease sometimes puts on the ap-
 the sight proceeds from an incipient-cata-  pearance of  an ulcerated, wart-like ex-
 ract,  or a defect of sensibility in the op-   crescence,  occasionally acquiring a consi-
 tic nerve,                               durable size.   Sometimes it  is seen in the
   The mode of applying it is to moisten  form of a very destructive  ulcer,  which
 the finger with  it, and  to rub it for two  consumes the surrounding substance ofthe 
LIP
LIT
171
lip*; and, in other examples, the disease re-
sembles a hard lump, which, at length, ul-
cerates.  The  disease, in  its  infancy, is
often no more than a pimple,  which gra-
dually  becomes malignant.   Whenever
there is reason to believe, that the disease
is of an unyielding cancerous nature, the
sooner it is extirpated the better   For
this purpose, some surgeons  admit the
propriety of using caustic, when the whole
disease can be completely destroyed by
Hey never rejects a patient on this ac-
count, provided such  state is habitual.
(Practical  Observations, p.  51.)  Scarpa,
however, recommends  relieving the liip-
pitudo before undertaking the operation,
as we  have explained  in the article Ca-
taract.
  See  Chandler on the diseases of the Eyes,
chap. 8 Scarpa sullc Malattie degli Occhi,
p. 244.
  LITHONTRIPTICS.  (from a<0«* a
one application.  But,  as  the action of  stone; and B-^vttu, to break.)  Medicines
caustic is not capable of being regulated
with so much precision as the extent of a
wound can be, and as caustic will not al-
low the parts to be united again, the knife
is the only justifiable means, especially as
it occasions also less pain.  Two incisions
are to be made, meeting at an angle below,
(supposing it to be the lower lip) and in-
cluding the  whole of the disease.  The
sides of the  wound are then to be united
with the twisted suture.   (See Hare-lip.)
When the affection is extensive, however,
the .surgeon  is frequently  necessitated to
remove the whole of the lip, or too much
of it to admit of the above plan being fol-
lowed.  This circumstance is particularly
unpleasant,  as the  patient's spittle can
for dissolving stones in the bladder, (See
Urinary Calculi.)
  LITHOTOMY  (from  Xttot, a stone;
and  TefMor, to  cut.)   The  operation of
cutting into tlie bladder, in order to ex-
tract a stone.
  It has been correctly remarked, that no
single operation of surgery has attracted
so much notice, or had so much written
upon it, as that of lithotomy.  A full and
minute account of the sentiments of every
writer, who has treated of" the subject, and
a detail of the infinite variety of particular
modes of making an opening  into the
bladder, would occupy as many pages as
are allotted to  the whole of this diction-
ary. It must be my endeavour, therefore,
only be prevented from continually running  ^  tQ descvihe what is most'interesting
over his chin by  some artificial contriv-
ance.  The deformity also is very  great,
and pronunciation and  swallowing  can
only be imperfectly performed.
  LIPP1TUDO (from lippus, blear-eyed.)
Blearedness.  The ciliary glands, and lin-
ing of the eyelids, only secrete, in the
sound state, a mere sufficiency of a seba-
ceous fluid to lubricate the parts in their
continual  motions.  But,  it  sometimes
happens, from disease, that this sebacious
matter is secreted in too great a quantity,
                                        and important, than pretend to offer an
                                        article which  is  to comprehend  every
                                        thing.
                                          May I be allowed  to  premise,  that
                                        throughout the following columns,  I sup-
                                        pose the reader well informed of all that
                                        relates to the anatomy of the bladder and
                                        adjacent  parts,  and  of  the  perineum.
                                        Without correct knowledge of this kind,
                                        a man must be presumptuous, indeed I
                                        who will set himself up for a good lithoto-
                                        mist; and if he distinguishes himself at
and glues the  eyelids  together* during  all, it will only be by the murders, which
sleep, so that, on Making, they cannot be  he commits, while his successful feats, if
easily separated.  Hence, the margin of  he achieve any at all,  will redound little
the eye-lids becomes red all round,  and
the sight itself even weakened.
  The best remedies are  the unguentum
hydrargyri nitrati,  smeared, at night, on
tile edges and inside of the eye-lid with a
hair pencil, after being melted in a spoon ;
the unguentum tutise, applied in the same
to his honour, since every young student
will soon find out, that they are not the
effect of science, but of mechanical habit
and imitation.  I  would  particularly re-
commend every one, who would wish to
become well acquainted with the anatomy
of the pelvis viscera and  perinaeum,  with
way; and acollyrium, composed of 9j. of  a view to lithotomy, in the  first place to
zincum vitriolatum in "jviij. of aquae rosae* dissect these parts himself, and then avail
  When alterative medicines are requisite,  himself of the valuable instructions to be
and two of guaiacum, put together with  Deuxieme  Recueil, planche 5 et 6; Hal-
soap,                                    ler's Inst Med. of Boerhaave, and Elem
  Persons who have lippitudo and cata-  Physiol.  Tom. 5; Morgagni, Adversar,
r.icls together, bear couching much better,  Anat 3, p. 82,97:  Camper's plates; Saba-
than one would expect from the'appear-  tier's Anatomy; John Bell's  Principles of
ance of the eyes in that disease ;  and Mr.  Surgery; Deschamp's Traite Historique, 
172
LITHOTOMY.
 &e.  de POperation de la Taille, Tom. 1,
 p. 7, &c.
   A few subjects which  are closely con-
 nected with the present,  will be found in
 other  parts of this  dictionary.  For  in-
 stance, the nature of stones in the bladder
 will  be  considered  under  the head  of
 Urinary  Calculi, where also will be seen
 some observations on lithontriptics. The
 manner of searching  for the stone, or as it
 is now more   commonly expressed,   of
 Sounding, will be explained in  the article
 Sounding
   Here 1 shall principally confine  myself
 to the symptoms of  the disease, and  the
 chief methods of executing the much di-
 versified operation of lithotomy.

         SYMPTOMS OF THF. STONE.

   The symptoms of a stone in the bladder
 are,  a sort of itching along the penis, par-
 ticularly at the extremity ofthe glans; and
 hence the patient frequently gets a habit
 of pulling the prepuce,  which becomes
 elongated; frequent  propensities to make
 water, and  go to stool; great  pain in
 voiding the urine, and difficulty of retain.
 ing it, and often of keeping the feces from
 being discharged at  the  same  time;  the
 stream of urine is liable to stop suddenly,
 while flowing  in a full current, although
 the bladder is  not empty, so that the fluid
 is expelled by fits, as it were ;  the painjs
 greatest towards the  end of, and just after,
 the evacuation; there is a dull pain about
 the neck of the bladder,  together  with a
 sense of weight, or pressure, at the lower
 part ofthe pelvis; and a  large quantity of
 mucus is mixed with  the urine; and,
 sometimes, the latter is tinged with blood,
 especially, after exercise.  (Sharp, Earle,
 Sabatier.)
  Frequently (says Deschamps) a patient
 will  have a stone in his  bladder a long
 while without  the occurrence being indi-
 cated by any symptom, or accident.  Most
 commonly, however, the presence of  the
 stone is  announced by pain in the kid-
 neys, more especially in • adults and  old
 persons, children scarcely ever suffering in
 this way,  because in them  the stone is
 hardly at all detained in the kidneys and
 ureters, but descends immediately into  the
 bladder,  the preceding  tubes  being  in
 them more dilatable,  and the rudiment, or
nucleus of the stone  smaller.
  It  seldom happens, that calculous  pa-
tients void blood with their urine,  before
the  symptoms  and  accidents,  usually
eaused by the stone, have  taken  place
It is not  till  after the foreign body has
descended into the bladder, acquired'some
$\ze, and presented itself at the oniice of
that viscus,  that pain is,occasioncd, par-
ticularly, when the surface ofthe stone is
unequal.  The patient then  experiences
frequent inclination  to  make water,  at-
tended  with pain. The jolting of a car-
riage,  riding  on horseback,  and much
walking,  render the pain more acute.
The  urine  appears  bloody,  and  its
course is frequently  interrupted,  and sa-
bulous  matter and particles of stone  are
sometimes discharged with it. The want
to make  water becomes  more  frequent
and  more  insupportable.  The  bladder
is irritated, and inflames ; its parieies be-
come thickened  and indurated; and its
diameter  is lessened.  A  viscid more or
less tenacious matter   is observed, in
greater or lesser quantity, in the mine,
and is precipitated to the  bottom of  the
vessel.  The urine becomes black and  pu-
trid, and  exhales an intolerable alkales-
cent smell which is perceived at the very
moment of the evacuation, and  is much
stronger a little while afterwards,  the
patient  can no longer use any  exercise,
without all his complaints being redoubled.
Whenever he walks in the least,  the urine
becomes bloody;  the pain about the hypo-
chondria, which was dull in the beginning,
grows more and more acute;  the ureters
and kidneys participate  in the  irritation
with the bladder; they  inflame  and sup-
purate,  and very soon the urine brings
away with it purulent matter.   The fe-
ver  increases, and changes  into one of
a slow type ; the patient loses  his sleep
and appetite;  becomes emaciated and  ex-
hausted; and death at length puts a period
to his misery.   (See  Traite  Historique et
Dogmatique de I'Operation de  'a Tuille par
J. F. L. Deschamps, Tom. 1, p. 163 ; Puns,
1796.)                       -
  It is acknowledged by all the  most  ex-
perienced surgeons, and judicious writers
upon the present subject, that the symp-
toms of a stone in the bladder, are exceed-
ingly equivocal, and  may be produced by
several  other  disorders!  " Pain in mak-
ing water, and not being able to discharge
the urine without the feces,  are common
consequences of irritation  of parts about
the neck of the bladder,  from a diseased
prostate gland, and  other causes.  The
urine stopping in a full stream is frequent-
ly caused by a stone "altering its situation,
so as to obstruct the passage;  but  tlie
same thing may happen from a tumour, or
fungus  in the'bladder.   I have  seen an
instance of this, where atuniour,  hanging
by a small pedicle, would sometimes cause
obstruction, and by altering the  posture,
would  retire,  and give  a free  passage.
The dull pain at the neck of the  bladder,
and tiie sensation of pressure on   the rec-
tum, are frequently owing to the weight
of the stone, &c; bin these may  proceed 
LITHOTOMY.
17*
from a diseased  enlargement of the pro-
slate  gland.   Children  generally,  and
grown persons frequently, are subject to a
profapsus ani,  from the irritation of a
stone  in the bladder; but it will likewise
be produced  by  an irritation  in  those
parts." (Earle)   The  rest of the symp-
toms are equally fallacious; a scirrhous
enlargement of the os  tincae, and disease
of the kidneys, may occasion a copious
quantity  of mucus in the urine, with pain,
irritation, &c.  "  The  least fallible sign
(says  Sir James Earle) which I  have re-
marked,  is tlie patient making  the first
portion of urine  with ease, and complain-
ing of great pain coming on when the last
drops are excelled.  This may readily be
accounted tor, f> om the bladder being at
first  defended from  contact  with  the
stone by the  urine; and,  at last,  being
pressed  naked against it.   But, to  put
the matter out of  all doubt, and actually
to prove the  existence of  a stone  in the
bLdder, we  must have recourse to the
operation of ,sounding."
   A stone in the ureter,  or kidneys, or an
inflammation  in  the  bladder, from  any
other cause,  will sometimes produce the
same effects; but if the patient cannot
Urine, except in a certain  posture, it is
almost a sure sign the orifice is obstructed
by a stone.  If he finds ease by pressing
against the perinaeum with his fingers, or
sitting with that part  upon a hard  body,
there is little doubt the ease is  procured
by taking off the weight ofthe stone ; or,
lastly,  if, with the other symptoms, he
tli inks  he can feel it roll in his bladder,
it is   hardly  possible  to   be mistaken;
however,. .the only sure judgment is to
be formed from searching.  (Sharp on the
 Operations )
   An enlarged prostate gland is  attended
wi'h  symptoms  resembling those  of" a
stoue in the bladder; but,  with this diP
fererice, that the  motion of a coach, or
horse, does not increase the  grievances,
when the prostate is  affected,  while it
does  so  in at* intolerable degree in cases
of stone.  It also generally happens, that
the fits of tiie stone come on at intervals;
whereas, the pain from a diseased prostate
is  neither so unequal,  nor so  acute.—
(Sfiarp in Critical Eiujiury,p. 165, Edit.4.)
   Though,  from a consideration  of all
the circumstances above related, the sur-
geon may form a probable opinion of there
being a stoue in tlie bladder, yet he must
never presume to  deliver a positive one,
nor ever he so rash as  to undertake litho-
tomy, without  having greater reason for
being certain  that there is a stone to  be
extracted.  Indeed, all prudent surgeons,
for centuries past, have laid it down as
an invariable maxim,  never to  deliver a
decisive judgment, nor undertake litho-
tomy,  without-having  previously intro-
duced  a metallic   instrument, called a
sound, into the bladder, and plainly felt
the stone.
  However, were the symptoms most un-
equivocal, there is one circumstance which
would always  render  it  satisfactory  to
touch the stone with an instrument,  just
before venturing to  operate;  I  mean the
possibility of there actually being a stone
in the  bladder  to-day,  and not  to-morrow.
It is now a  well-known fact, that stones
are occasionally  forced,  by the violent
contractions ofthe bladder, during fits of
the complaint, between the fasciculi  of
the muscular coat of tlus viscus, together
with a portion  of the membranous lining
of the part, so as to become what is termed
encysted.   The opening into the cyst is
frequently very narrow, so that the  stone
is much bigger than  the  orifice  of the
cvst, in consequence of which it is impos-
sible to lay hold of the extraneous body
with the forceps, and the operation would
necessarily  become fruitless.   {Sharp's
Critical Enquiry, p. 228, Edit 4.)
   In the article Urinary  Calculi, I  have
noticed the probability of this  having oc-
curred in some of the instances, in which
Mrs. Stevens's  medicine was supposed to
have  actually  dissolved the  stone in the
bladder ; for,  an encysted stone is not
likely  to  be hit with  the  sound, nor  to
cause any  inconvenience, compared with
what, a calculus, rolling about in the blad-
der, usually occasions
   It is noticed by  Deschamps,  that when
the stone is lodged in an excavated corner
ofthe bladder, in a particular cyst, or de-
pression ; when it projects but  very little^
when it cannot shift its situation in the
bladder, so as to fall against the orifice of
this viscus ; and when it  is also  smooth,
polished, and light; the patient may then
have it a long while, without experiencing
any  afflicting symptoms.   He  may  even
live to  an advanced age, if not  without
some degree of suffering,  at most  with
such  pain  as is very supportable.  Daily
experience proves,  that persons may live
a considerable time,  with one,  two, or
even  three stones  in  the bladder,  and,
during the whole of their lives, have not
the  least suspicion of the existence of
these foreign bodies.
   According to  Deschamps,  this  must
have  been  the case of M.  Portalieu, a
taylor, in the  street Sepulchre. This in-
dividual,  eighty years  old, was frequently
attacked  with  a retention  of urine  from
paralysis,  and had consulted Deschamps
two years previously. This surgeon intro-
duced a  sound several times, and dis-
tinctly felt a stone in  the bladder.  The. 
174
LITHOTOMY.
 patient, however, never had any symptom
 ofthe disorder,  not even up to the period
 when Deschamps was writing down the
 case in his excellent treatise.  Very large
 and exceedingly rough stones have  also
 been found in tiie dead bodies of certain
 persons, who had never complained ofthe
 symptoms of the disease.  But, cases of
 this kind must be extremely rare, because
 it is well known,  that the pain, which a
 stone produces, is  less in a ratio to its
 size, than to its shape and situation.  A
 small stone, owing to its  situation, may
 be more painful, than an enormous calcu-
 lus, which fills the bladder,  as  is proved
 by the  following  case,  cited  by  De-
 schamps.                             4
   Pochet, a watchmaker, until the age of
 45, had never had any infirmity, except
 that of not being able to-retain his water
 a  long  while.   One day,  while he  was
 carrying a very heavy pendulum, he made
 some exertion, which, probably by chang-
 ing the situation of the calculus,' caused
 at the instant an acute pain  in the hypo-
 gastric region   Symptoms  of the stone
 soon came on;  the pain became intoler-
 able;  and the patient  went into the* H6-
 pital de la  Charite".   He  was sounded;
 the stone was  felt,  and judged to be of
 considerable  size.  The  incision in  the
 heck of the bladder not sufficing for  its
 extraction, the  patient was put to  bed
 again.  The next morning, he was ope-
 rated  upon  above the pubes by  Frere
 Come, who  extracted  an  oval calculus,
 that weighed twenty-four ounces.  The
 patient died four and twenty hours after
 this second operation.  This case proves
 then, that very large stones may lie a long
 while in the bladder without occasioning
 any serious complaints, since the preced-
 ing patient apparently had such a calculus
 a long time,  without suffering  inconve-
 nience from  it,  and  it seems likely that
 he might have continued well still longer,
 had it not been for the accidental effort,
 which first excited the symptoms. (De-
schamps, in  Traite Historique, &c. de la
 Taille,  Tom. 1, p. 166,  167.)
   With perfect impartiality, I shall next
concisely describe the various methods of
cutting for the stone,  beginning with the
most ancient, called the apparatus minor,
and ending with  the modern proposal of
employing a knife in  preference to a gor-
get.


 OF THE APPARATUS MIJJOJl, CLTTIKG OX THE
      GHirE, Oil CELSUS's METHOD.


  The most  ancient  kind of lithotomy
 was that practised upwards of two thou-
sand years  ago, by  Ammonius, at Alex-
andria, in  the  time of  Merophilus  and
Erasistratus, and  by  Meges,  at Rome,
during the reign of Augustus;  and, being
described hy Celsus, is named, Lithotomia
Celsiana.  From cutting directly on the
stone, fixed by the pressure ofthe fingers
in the anus, it has beeft called,  cutting on
the gripe, a knife and a hook  being the
only instruments used.  The appellation
of the lesser apparatus, was given to it
by Marianus, to distinguish it from a me-
thod which he described, called the appa-
ratus major, from the many instruments
employed.
  The operation was done in the  follow-
ing way.  The rectum  was emptied by a
glyster, a few hours previously ; and, im-
mediately before cutting, the patient was
desired  to  walk  about his  chamber, to
bring the stone down  to  the neck of the
bladder; he  was then placed in the lap
of an assistant, or secured as now,  in the
lateral operation.   The  surgeon then in-
troduced the fore  and middle  fingers of
his left  hand, well oiled, into  the anus;
while he,atthe same timejiressed with the
palm of his right hand on the lower part
of the abdomen, above tlie pubes, to assist
in bringing down  the stone.   With  the
fingers, it is next to be griped, pushed
forward toward the neck of the bladder,
made to protrude,  and form a tumour on
the left side of the  perinaeum.  The ope-
rator then took a scalpel,  and  made a lu-
nated incision through the skin and cellu-
lar substance, directly on the stone,  and
near the auns, down to the neck of the
bladder, with the horns towards the hips.
Then, in the deeper and narrower part
of the wound, is to be made a second in-
cision, also transverse, into the neck of
the bladder itself, till the flowing out of
the iirine shews the incision to  exceed in
some degree, the size ofthe stone.  The
calculus,being strongly pressed upon with
the fingers, next started out of itself, or
was extracted with a hook  for the pur-
pose.   (Celsus, lib  7,'  cap. 26.  J. Bell's
Principles,  Vol 2, p. 42.  Allan on Litho-
tomy, p. 10.
  The objections to cutting  on  the gripe,
are, the impossibility of  always dividing
the same parts;  for, those which are cut
will vary, according to the degree of form
employed in making the stone  project in
the perinaeum.   When little exertion is
made, if the incision be begun just behind
the scrotum, the urethra may be  altoge-
ther detached from the prostate ; if the
stone be much pushed out, the bladder
may be entered beyond tiie prostate,  and
both the vesiculz seminales  and vasa de-
ferentia inevitably suffer.  Lastly,  if the 
LITHOTOMY.                            175
parts are just sufficiently protruded, the
bladder will be cut upon its neck, through
the substance of the prostate gland. (Al-
lan on  lithotomy.  Bums, in  Edinburgh
Surgical Journal, No. XIII.  J. Bell, Vol.
2, p 59.)
  The  preceding dangers were known to
Fabricius  Hildanus,  who attempted to
obviate them by cutting on a staff, intro-
duced  along the urethra into the bladder.
He began  his incision in ,the perinaeum,
about half an inch on the side of the raphe;
and he continued the cut,  inclining the
knife,  as he proceeded, towards the hip.
He continued to divide the parts till he
reached the staff;  after which, he enlarg-
ed the wound to such an extent, as to per-
mit him easily to extract the stone, which
he had previously brought  into the neck
of tiie bladder, by pressure with the fin-
gers in the rectum.  He employed a hook
to extract  the  stone.  (Burns )  In this
way Mr. C. Bell has operated with suc-
cess. (/. Bell.)
    The apparatus minor,  as  practised by
 Fabricius,  with the aid of  a staff, is cer-
 tainly  so simple and safe an operation for
 children, that we  must lament its present
 utter neglected state.  You cut, says an
 eminent writer, upon  the stone, and cut
 of course, with perfect security, an incision
 exactly proportioned  to its size.  There
 is no  difficult nor dangerous  dissection;
 no gorget, nor otlw dangerous  instru-
 ment,  thrust into the bladder, with the
 risk of its passing betwixt that and the
 rectum; you are performing, expressly,
 tlie lateral incision of Raw and Chesel-
 den, in the most simple and favourable
 way.   (/.  Bell)  The  prisca simplicitas
 instrumentwum seems, indeed, as the latter
 gentleman remarks, to have been forsaken,
 for the sake of inventing more ingenious
 and complicated operations.
    Celsus  has delivered one  memorable
 precept in  his description of  lithotomy,
 utplagapaulo major, qudm calculus sit; and
 he seems to have  known very well, that
 there  is  more  danger  from lacerating,
 than cutting the parts.
    The simplicity of the operation embol-
 dened every quack, to undertake  its per-
 formance ; and thus,  by diminishing the
 emolument  of regular  practitioners, be-
  came  the  grand cause of  its downfall.
  ^See  Heister on this subject.)  It was long-
 er practised, however, than all the other
  methods; and  was performed  at  Bour-
  deaux, Paris, and other places in  France,
 on patients of all ages, by  Raoux, even
  as late as 140 years ago.  Frere Jacques
  occasionally  had recourse to it; and it
  was  successfully executed  by   Heister.
  {/'art 2,  cf&p. 140.)  A  modern author
recommends it always to be preferred on
boys,  under fourteen.  (Allan, p. 12.)

           APPARATCS MAJOB.

  So named from the multiplicity of instru-
ments employed; or the  Marian method,
from having been first published by  Ma-
rianus Sanctus, in 1524, as the invention
of his master, Johannes de Romanis. (See
J\Ua-ianus de lapide Vesicx per incisionem
exlrahendo )
  This operation, which came into vogue,
as  we  have  noticed,  from  avaricious
causes,  was rude and painful in its  per-
formance, and very  fatal  in its  conse-
quences.  The apology for its  introduc-
tion, was the declaration of Hippocrates,
that wounds of membranous parts are mortal.
It  was  coin ended, however, that such
parts might  be  dilated  with impunity;
and, on this principle of dilatation, Ro»
manis invented a complex and dangerous
plan of operating; one very incompetent
to  fulfil the end proposed;  one, which,
though supp6sed only to dilate, really la*
cerated tlie parts. (Burns )
   The operator, kneeling  on one knee,
made an  incision, with his razor, along
the perinaeum, on one  side of the raphe ;
and,  feeling with his  little finger for the
curve of the staff, he opened the membra-
nous part of the urethra; and,  fixing the
point  of the knife in the groove of his
staff, gave it to an assistant to hold, while
he passed a probe along the knife into the
groove of  the  staff", and  thus into the
bladder.  The urine now flowed out, and
the staff  was withdrawn.  The operator
next took two conductors, a sort of strong
 iron probes; one, named the female  con-
ductor, Iiaving in it a groove, like one of
 our  common directors; the other, the
 male conductor, having a  probe point,
 corresponding with  that groove.  The
 grooved, or female conductor, being in-
 troduced along  the probe into the  blad-
 der,  the  probe was  withdrawn, lind the
 male conductor passed along the groove
 of the female one, into the bladder.  Then
 commenced the operation  of dilating.
 The lithotomist took a conductor in  each
 hand, and, by making their shafts diverge,
 dilated, or, in plain language, tore  open
 the prostate gland. (/. Bell)
    It would be absurd  in us to trace the
 various  dilating instruments, contrived
 for the  improvement of  this barbarous
 operation, by the CoHots, Le Dran,  Pare,
 &c.  Among the numerous glaring objec-
 tions to  the apparatus major, we  need
 only notice the cutting the  bulb of the
 urethra,  not  dividing the  membranous
 part of the urethra, nor the transversalis 
176                             LITHOTOMY.
 perinei muscle, which forms a kind of bar
 across the place where the stone  should
 be extracted;  the laceration of  the neck
 of the  bladder; frequent  impotency af-
 terwards,  and extensive  fatality.—Pare,
 Le Dran, Le Cat, Mery,  Morand,  Mare-
 schal, Raw, and all tlie best surgeons in
 Europe, most strangely practised this
 rash method, for two hundred years, till
 Frere Jacques, in 1697,  taught at Paris
 the original model of  lithotomy, as com-
jmonly adopted at the present day.

         OF THE HIGH OPERATION.

   This method of cutting for the  stone,
 was first published  in  1561, by Pierre
 Franco, who,  in his  Treatise on Hernia,
 says, he once performed it on a child, with
 very good  success, but discourages  the
 farther practice of it.   After him, Rosse-
 tus  recommended it, with great  zeal, in
 his book intitled Partus Cxsarius, printed
 in  1591; but  he  never performed the
 operation himself.—Monseur Tolet makes
 mention of its Iiaving been tried in  the
 MoteUDieu, but without entering into the
 particular  causes of  its  discontinuance,
 says only, that it was found inconvenient
 About the  year 1719,  it was first done  in
England, by  Mr.  Douglas;  and after
him, practised by others.  (Sharp's  Ope-
rations.)
  The patient  being laid on a square ta-
ble, with his legs hanging  off, and fas-
tened to the sides of it by a ligature, pass-
ed above the knee, his head and body lift-
ed up a little  by pillows, so as  to relax
the  abdominal muscles, and  his  hands
held  steady by  some assistants; inject
through a  catheter, into the bladder,  as
much barley-water as he can bear, which,
In a man, is often about eight ounces, and
sometimes  twelve.
  The bladder being filled, an assistant,
in order to prevent the reflux of the wa-
ter,  must grasp the penis, the moment the
catheter is  withdrawn, holding it on one
side, in such a manner as not  to  stretch
the  skin of the abdomen; then, with a
round-edged knife, make an incision about
four inches long, between the  recti and
pyramidal   muscles, through  the mem-
brana  adiposa, as deep as the  bladder,
bringing its extremity almost down to the
penis;  after this, taking a crooked knife,
continue the incision  into the  bladder,
carrying it a little under the os pubis;
and  immediately upon the  water's flow-
ing out, introduce the fore-finger of your
left hand, which will direct the forceps to
the stone. (Sharp's Operations.)
  Although this is one of the easiest, and,
to all appearance, the  safest method of
 operating, several objections soon brought
 it^into disuse.  1. The irritation of a stone
 often causes such  a thickened and con-
 tracted state of the bladder, that this vis-
 cus will not admit of being distended so
 as to rise above the pubes.  2.  If the ope-
 rator should  break  the stone, the frag.
 ments cannot be easily washed  away,  and
 remaining behind  would form a nucleus
 for a future stone.  3. The urine may be-
 come  extravasated.  4- The   danger of
 exciting inflammation of the peritona:uni.
 5. The  injection  itself  is  exceedingly
 painful, and, however slow the fluid be in-
 jected, the bladder can seldom  be dilated
 enough to make the  operation  absolutely
 secure; and,  when hastily  dilated, it is
 sometimes  even  burst, or, at least, its
 tone destroyed.  We need not  enumerate
 other inconveniences. (See  Sharp, Allan,
 &c)
   Some of the objections, however, da
 not  apply to certain  instances.  In many
 men, we  know by searching,  that their
 bladder is very large, so that we can  nin
 no risk of meeting with it in a contracted
 state, and therefore, the objection is of
 no weight,  when we are certain, that  the
 bladder extends itself a considerable way
 above  the pubes, and will admit  a large
 quantity  of injection.  Stones are some-
 times known to be of large size, and they
 are  less likely to be broken in  this, than
 any other kind of lithotomy, so that  the
 objection  of the  difficulty  of extracting
 small ones and fragments,  is   less  forci-
 ble.   The excoriations,  from the effusion
 of urine all over the skin near the wound,
 may be prevented by  embrocations, oint-
 ments, &c.  The abscesses and gangrenes,
 arising  from the extravasation of urine in
 the cellular substance, may  be very much
 prevented by the introduction  of  a can-
 nula, as practised in the puncture of  tlie
 bladder above  the os pubis.   (Sharp in
 Critical Enquiry.)
   This  celebrated  surgeon remarks, in
 the same  chap. I,  that he should  not be
 surprised,, if hereafter, on particular occa-
 sions, the high operation should be reviv-
 ed and practised with success.

          LATERAL OPERATION.

   So named from the prostate  gland,
 and neck  of the bladder, being laterally
 cut.
  It was invented by  an ecclesiastic, who
 called  himself Frere Jacques: he came
 to Paris in 1697, bringing with him abun-
 dance of  certificates of his  dexterity in
operating; and making his history known
to the court and magistrates of  the city,
 he got an  order to cut at the Hotel-Dieu, 
LITHOTOMY.                             177
»;.;1 the Charite, where he performed this
operation  on  about  fifty persons.  His
success did  not answer the promises  he
had made, .and from that time his reputa-
tion seems to have declined in the world,
if we may give credit to Dionis, who has
furnished us  with  these particulars.—
(S/iarp's Operations.)
  Fi ere Jacques used  a big round staff
without a groove,  and when it was intro-
duced into the bladder, he depressed  its
handle,  with an intention of  making the
portion of this viscus, which he wished to
cut,  approach the  perina:um.  He  then
dunged a long dagger-shaped knife into
the left hip, near the  tuber  isch'n, two
fingers breadth from the perinaeum, and
[lushing it towards the bladder, opened it
in its body, or as near the neck as  he
could, directing his incision upward from
the anus.  He  never withdrew his knife,
till a sufficient  opening was made for the
extraction of the  stone.  He  used some-
times a conductor to guide the forceps,
hut more commonly, directed them  with
his finger, which  he  passed into the
wound  after   withdrawing   the  knife.
When  he  got hold  of the stone,  he
used to draw it out in a quick  rough man-
ner, heedless  of  the bad consequences.
His only object was to get the stone ex-
tracted, and he disregarded every thing
else; all preparatory  means,  all dress-
ings, all alter treatment. (Allan, p. 23.)
  Totally ignorant of  anatomy, and thus
rude and indiscriminate in practice, Frere
Jacques soon sunk into disrepute.  How-
ever, there were several eminent surgeons,
who conceived,  from  considering the
parts, which  he  cut,  that  his  metliod
might  be converted into a  most useful
operation.  (Sharp's  Operations.)
  The  principal defect, in his first man-
ner of cutting,  was the want of a groove
in his staff, w hich made it difficult to carry
the knife into   the  bladder.   At length,
Frere  Jacques was prevailed upon  to
study anatomy, by  which his judgment
being improved, he readily embraced se-
veral improvements, which were suggest-
ed to him. Indeed, we are informed, that
he now succeeded better, and knew more,
than is generally imagined.  Mr. Sharp
i:iys, that when he himself was in  Fiance
in 1702, he  saw a pamphlet, published by
this celebrated character, in which his
metliod of  operating appeared so much
improved, that it  scarcely differed  from
the practice  of that time.  Frere Jacques
had learnt tiie necessity  of dressing the
wound after the operation, and had pro-
fited so much from the criticisms of Mery,
l'agon, Felix, and Hunauld, that he then
used a staff  with  a groove, and, what is
more extraordinarv, had cut thirty-eight
    Vol.  If.
patients successively, without losing one.
(Sharp's Operations.)
  In short, as a modem writer  has ob-
served, he lost fewer patients, than we do
at the present day, in operating with  a
gorget.  He is  said to  have cut nearly
5000 patients in the course  of his  life,
and, though  persecuted by the regular
lithotomists, he  was imitated by Mare-
schal at Paris,  Raw in  Holland, and by
Bamber  and  Cheseldon in  England,
where  his operation   was  perfected.—
(Allan.)
   For  a   particular  history  of |Frere
Jacques, and his operations,  Allan refers
us to Bussiere's  Letter to Sir Hans Shane,
Philos. Trans. 1699.  Observations sur la
Muniere de tailferdans les deux Sexes, pour
I' Extraction dela Pierre, pratiquee par F.
Jacques, par J. Mery.   Lister's Journey to
Paris in  1698.   Cours cF Operations  de
Chirurgie, par Dionis.  Garengeot's Traite
des Operations, Tom. 2. Morand, Opuscules
lie Cldrurgie,  Part 2.
  Among   the  many,  who saw Frere
Jacques operate, was the famous Professor
Raw, who  carried his method into Hol-
land, and practised it with amazing suc-
cess.  He never published any account of
it himself, though  he admitted several to
his operations; but, after his death, his
successor Albinus,  gave the world a very
circumstantial detail of all the processes,
and mentions, as one of Raw's improve-
ments, that he used to open  the bladder,
between the  neck and the ureter. But,
either  Albinus, in  his  relation, or Raw
himself in  supposition, was mistaken;
since it is  almost impossible to cut the
bladder in that part upon the common
staff', without also wounding the neck.
(Sharp in  Operations,  and  Critical En-
quiry.)
  Raw's method was objectionable, even
when accomplished, as the  urine could
not  readily escape, and became extrava-
sated around the rectum, so as to produce
terrible mischief.   There  is little doubt,
that Raw's really  successful plan, was
only imitative of Frere Jacques' second
improved one, though he had not the ho-
nour to confess it.   (See Ferhius de Cal-
cuh Vesicx.)
  Dr. B amber was the first man  in Eng-
land, who made a trial of Raw's metliod
on the living subject, which he did in St.
Bartholomew's Hospital.  Cheselden, who
had been in the habit of  practising  the
high operation, gladly abandoned it,  on
receiving the account  of Raw's plan and
success, and, a few days after Bamber, he
began to cut in tins way in St. Thomas's
Hospital.
  Cheselden  used  at  first to operate m
the following manner.   The patient  be*
    Z 
178
LITHOTOMY.
     ing placed,  and tied much irt the  s:,me
     way, as is done at this diy, the operator
     introduces a hollow grooved steel catheter
     into  the bladder, and with  a syringe,
     mounted with  an  ox's ureter,  injects as
     much warm water into it,vus  he  patient
     can bear without pain.  The water being
     kept from running out by a slip of flannel
     tied round the penis, the end of  the ca-
     theter is to be held by an assistant, whose
     principal care is to keep  it from  rising,
     but  not at all  to  direct the groove to
     the  place, where  the  incision is to be
     made.?
       With  a  pointed convex-edged knife,
     the  operator beginning  about an  inch
     above the anus, on  the left side  of the
     raphe, between the accelerator urinae, and
     erector penis, makes an  incision down-
     wards, by the side of the sphincter ani, a
     little obliquely outwards as it descends,
     from two and  a  half* to  four inches in
     length, according to the age of the  patient,
     or size and structure of the parts.  This
    incision,  he endeavours to make all at one
    stroke, so as to cut through the skin, fat,
    and all, or part, of the levator ani, which
    lies in his way.  This done, he passes his
    left forefinger into  the  middle  of the
    wound,  in order to press the rectum to
    one side, that it may be in less danger of
    being cut; and taking a crooked knife in
    his other hand, with  the edge on the con
    cave side, he thrusts the point of it through
    the wound,  close by his  finger, into the
    bladder,  between the vesicula seminalis
    and os ischium of  the same  side.  This
    second incision is continued upwards, till
    the point of the knife comes out at the
    upper part of the first.  The incision be-
    ing completed, the  operator  passes his
    left  fore-finger through  the  wound into
    the bladder, and having felt, and secured
    the stone, he introduces the forceps, pulls
    out his finger, and extracts the stone.
      As the bladder was distended,  Chesel-
    den thought it unnecessary to cut on the
    groove ofthe staff, and that, as  this viscus
    was sufficiently pressed down  by  the in-
    strument, the forceps could be very well
    introduced, without the use of any direc-
    tor, except the finger. (Postscript to Dou-
*  glas's History of the  Lateral  Operation.
    1726.)
      W ith respect to this first of Cheselden's
    plans, Sharp  says, the  operations  were
    exceedingly dexterous; but the wound of
    the  bladder  retiring  back,  when  it was
    empty, did not leave a  ready issue for
    the urine, which, insinuating itself among
    the  neighbouring muscles and cellular
    substance, destroyed four of the ten that
    he practised it upon, and some  of the
    •thers narrowly escaped.   (Sharp's Ope-
    rations.)
  Cheselden, finding that he lost so many
of his patients, in imitating Haw, as Al-
binus directed, Deg.m  to  adopt a  new
manner of operating, founded on the ana-
tomy of the parts, which he  thus  de-
scribes : " I first  make as long an ircision
as 1  well can, beginning near the place,
where the old operation ends, and cutting
down between the tmiscmus accelerator
urinae and erector penis, and by the side
ofthe inlestinum rectum ;  I then feel for
the staff", and cut upon it the length ot the
prostate gland  straight on to the bladder,
holding down the gut all the  while with
one, or two fingers of my left hand." (Ana-
tomy of the Human Body, Edit. 1~30.)
  It deserves  to  be remarked,  it was
Cheselden's  second manner of cutting, >>
that has been described in the Opuscule*
de Chirurgie of M. Morand, who was de-
puted, and had his expences defrayed, by
the Royal Academy of Sciences in Paris,
to con.e over to England,  Mid learn from
Mr.  Cheselden himself,  his way of operat-
ing for  the  stone; and,  accordingly  we
find, that most  French authors, taking
their account from M.  Morand, describe
Mr.  Cheselden's  second,  not  his  third
operation, as that which he invented, and
bears his name.  But, that Mr. Chesel-
den  never resumed his  second manner of
cutting,  may  be presumed from his con-
tinuing  to describe the third only in all
the editions of his anatomy published af-
ter 1730.  (See a note by J. Thomson, M. I).
annexed to hisitew edition of Douglas s Ap-
pendix.   Edinburgh, 1808.)
  The instruments, which Cheselden em-
ployed  in his third, and most improved,
mode  of cutting for  the stone, were a
staff, an incision knife, a  gorget, a pair
of forceps, and a crooked needle carrying
a waxed  thread.   The   patient  being
placed on a table, his wrists are brought
down to the  outsides of his ankles, and
secured  there  by proper  bandages, his
knees  having first been  bent, and his
beds brought back near his buttocks.
  Mr. Cheselden used then to ti.ke  a ca-
theter, first dipped in  oil,  and  introduce
it into the bladder, where having searched
for,  and discovered the stone, he used to
give the instrument  to one of his col-
leagues, whom he desired to satisfy him-
self, whether there be a  stone, or not.
The assistant, standing on his right hand,
held the handle of tiie staff" between his
fingers and thumb, inclined it a little to-
wards the patient's right thigh, and drew
the convex side close up to the  os pubis,
in order to remove the urethra as far as
possible from the rectum.
  The  groove of the  staff' being  thus
turned outwardly and laterally,  Chesel-
den used to sit down in a low chair, and,   * 
LITHOTOMY.
179
keeping tlie skin of tiie perinaeum  steady
with the thumb and forefinger of his left
hand, he made the  first, or outward inci-
sion, through the integuments, from above
downwards, beginning on tiie .eft  side of
the raphe, between the scrotum and verge
of tlie anus, almost as high up as where
the skin of the perinaeum begins to form
the bag conta'niing tlie testicles.  Thence,
he continued  tiie wound obliquely out-
vv.u-ds, as low down as the middle  of the
margin of the anus, at about half an inch
distant from it near the skin, and,  conse-
quently,  beyond the tuberosity of  the is-
chium.  He was always caiefiil to make
tli is outward wound as large  as he could
with safety.   Having  cut the fat  rather
deeply,  especially near  the rectum, he
used to  put  his left forefinger into the
wound,  and keep it there till the internal
incision  was quite finished; first to direct
the point of his knife  into the groove of
his staff, which he,  now felt with the end
of his finger, and likewise to hold down
the rectum, by the side of which his knife
was to  pass, and so  prevent, its being
wounded.  This inward incision Chesel-
den i made with  more caution, than the
former.   His knife first entered the groove
of the rostrated,  or straight part  of the
catheter, through the  sides  of the blad-
der, immediately above tiie prostate, and,
afterwards, the /point of it continuing to
run In  the same  groove  in a direction
downwards,  and forwards,  or towards
himself, he divided that part of the sphinc-
ter of the  bladder, which lies upon that
gland, and then he cut the outside of one
halfofit obliquely, according to the direc-
tion and whole  length  of the urethra,
that ran within it, and finished his  inter-
nal incision,  by  dividing the muscular
portion of. the urethra on the convex part
of his staff.
  A sufficient opening being made, Che-
selden used to rise from his chair, his fin-
ger still remaining in  the wound.   Next
he put the beak of his gorget in the groove
of the staff, and then thrust it  into the
bladder.   The staff" was now  withdrawn,
and, while he. held  tlie  gorget with his
left hand, he introduced the forceps with
the flat side uppermost, sliding them with
great caution along the concavity of the
gorget   When they were in the bladder,
he  withdrew  the latter  instrument, and
taking hold  of the two  branches  of the
forceps with  both his hands, he searched
gently  for the stone,  having them still
shut.  As soon as this was felt, he used
to open them, and  try to get the tower
blade under the stone, that  it may fall
more conveniently into their chops, and
be laid  hold  of.  This  being done, the
stone was extracted with a very slow mo-
tion, in order to give the parts time to
stretch and dilate,  turning the forceps
gently in all directions
  When the stone was very small,  and
did not lie well in the forceps, Cheselden
used to withdraw them, and introduce his
finger into the bladder, in order to tiy
to turn the stone,  and disengage it from
the folds ofthe  lining of the bladder, in
which  it  is sometimes entangled.  Then
the gorget was passed in again on the up-
per side of his finger, and turned as  soon
as the  latter was pulled out;  the for-
ceps were introduced, and the stone ex-
tracted.
  To preserve a soft stone from breaking,
during its extraction, he used to put one
or  more  of  his  fingers  between  the
branches of his  forceps, to prevent any
greater pressure upon it than  what  was
just necessary to hold it together.   But,
when it did break,  or  there were more
than one,  he used to extract the single
stones,  or  fragments, one  after another,
repeating  the introduction of  his  fingers
and forceps, as often as there  was occa-
sion.  Cheselden took care not to thrust
the forceps so far into the bladder as to
bruise,  or  wound its opposite side; and
he was equally careful not to pinch any
folds of" its inner coat.  In this way,  Che-
selden saved 50 patients out of 52, whom
he  cut successively  in St Thomas's  Hos-
pital.   (Appendix to the  History of the La-
teral Operation, by J. Douglas.  1731.)
  Cheselden, with all the enthusiasm of
an inventor, believed, that he had disco-
vered an operation, which was not suscep-
tible of improvement;   yet, he  himself
changed the manner of his  incision no
less, than three times in the course of a
few years.   1st,  He  cut into the body of
the bladder, behind the prostate, when he
imitated  Raw.   2dly,   He cut  another
part ofthe bladder, viz. the neck" and the
thick substance of the prostate;  tins is
his lateral  mode of incision.  3diy, He
changed a third time, not the  essential
form of the incision, but,  the direction,
in which he moved the knife;  for, in his
first operation, when imitating  the  sup-
posed operation of Raw and Frere Jacques,  ^
he struck his knife into the body  of the
bladder, betwixt the tuber ischii and the
vesiculae seminales,  and all his  incision
lay behind  the  prostate gland.   In his
second operation, he struck his knife into
the membranous part of the urethra, im-
mediately behind the bulb,  and  ran it
down through the substance of the gland;
but, his incision stopped at the membra-
nous part, or body, of the bladder   But,
in his third operation, he, af er very large
external incisions, struck his knife deeply
into the great hollow  under the tuber 
-180                            LITHOTOMV
ischii,  entered it into the  body of the
bladder,  immediately behind  the gland,
and, drawing the knife towards him, cut
through the whole substance of the gland,
and even a part of the urethra, " cutting
the same  parts the  co/itrary  way." * By
carrying the forefinger of the left hand
before the knife, in dissecting towards
tiie body ofthe bladder, he protected the
rectum more perfectly, than he could do
in running the knife backwards along the
groove of the staff"; and by  striking his
knife into the body  of the  bladder, and
drawing it towards him, through the whole
thickness of the  gland, he  was sure  to
make an ample wound.  (J. Bell's Princi-
ples of Surgery, Vol.2, Part 1, p. 152.)

LATrllAL 0PERATIOX  AS rF.KFOUMED - AT THE
   PKESENT DAY WITH CUTTING GlinOKTS.

   The gorget is  the same instrument  as
the conductor  used  by  Hildanus; but,
having a cutting edge;  and  it was used
in the Marian operation as  a dilator and
conductor  for the  forceps.   Sir  Cxsar
Hawkins thought, that,  when its "fight
side was sharpened  into  a cutting edge,
it might be pushed safely ifito the bladder,
guided by the staff, and make tiie true
lateral incision,  in  the  left  side  of the
prostate gland, more easily, and with less
risk of injuring  the adjacent parts, than
 Cheselden could  do with the  knife,  and
 surgeons were pleased with a contrivance,
 which saved them from the responsibility
 of dissecting parts, with the anatomy of
 which all were not equally  well acquaint-
 ed.  (J. Bell. Allan.)
   When the patient is of a plethoric ha-
■fcit, 16, or 20 ounces of blood should be
 taken from his arm two  days before the
 operation;  a brisk purge  administered
 the day before;  and a clyster injected a
 couple of hours before cutting, in order
 to empty  the rectum, and render it less
 liable to be wounded.  It is to be lament-
 ed, that these prudent steps are so often
 neglected.
    As it is advantageous to have the blad-
 der  somewhat distended with urine,  they
 patient should be requested  to retain it a
 certain time before being cut.  When this
 cannot be done,  as in children, some ad-
 vise tying a ligature round the peuie,  or
 applying, what is called,  a j.igum, to pre-
 vent the patient from making the evacua:
 tion.  The best practitioners in London,
 however, do not commonly adopt tins me-
 thod.
    Before the operation, the  following in-
 struments should  all be arranged ready
  on a table: three grooved  stall's, of va-
 rious sizes ; a sharp gorget  with  a beak
nicely  anil  accurately  adapted  to UV
grooves of the staffs, so as to glide easily
and securely;  a large scalpel for  making
the  first  incisions; forceps,  of  various
sizes,  for extracting the stone ; a blunt-
pointed bistoury for enlarging the wound
in the  prostate, if the incision of the gor-
get is  not sufficiently large, as the parts
should never be lacerated : a pair of Le
Cut's  forceps with  teeth for breaking the
stone,  if  too large  to  come through any
wound reasonably  dilated ;  a syringe for
injecting   the  bladder, if" necessary,  ti»
wash out  clots of blood,  or particles ot
the stone  ; a scoop for the latter purpose;
two garters to tie the  patient's hands  to
his feet.
   After introducing the staff, and feeling
that the stone is certainly  in the bladder,
the  patient is to be secured in  the same
position,  as we described in the  account
of Cheselden's latest method of operating.
   The assistant, holding up the scrotum,
with his  left hand,  is  with his right  to
hold  the  staff", inclining  its handle  to-
 wards the right  groin,  to  make the
 grooved convexity of the_.instrument turn
 towards  the  left side of the  perinaeum.
 Some operators, also, like the assistant
 to depress the handle of the staff towards
 the patient's  abdomen, in order to make
 its  convexity project in  the perinaeum,
 while others condemn this plan, asserting,
 that it withdraws the  instrument from  the
 bladder.   (Allan, &c)
   The first incision should always com-
 mence, below the bulb of the urethra, over
 the membranous part of this canal, at  the
 place, where the operator means to make
 his first cut into the  groove  of  the staff,
 and the  cut  should extend  about three
 inches, obliquely downward, to the left of
 the raphe  of the perinaeum, at equal  dis-
 tances from the tuberosity of the ischium
 and the anus.  In a large man, the*fii st cut
 should pass the  anus an  inch and a  half
 or more  ; for, it is a general rule in sur-
 gery  to  make free external  incisions, by
 winch the surgeon.is enabled to conduit
 the remaining steps, of his operation with
 greater facility,  and no where is  it so ne-
 cessary as where a stone is to be extract-
 ed.   {Allan.) Tiie next object is to di-
 vide  the  transversales perinaei  muscles,
  which stand,  like a bar,  across  the trian-
  gular hollow, out of which alone the stone
  can  be  easily extracted.  An opening is
  next  to be made into the membranous  part
  of the urethra,  and now the operator has
  to  accomplish  a very important object,
  and one  which is, for the most part,  very
  much neglected;  1 allude to dividing the
  urethra, with the knife, as far as possible
  along the groove of the staff*, towards tlie 
LITHOTOMY.                            181
  Madder.   When this is  properly done,
  very little remains-to be effected  by that
  rougher instrument, the gorget.
     Having placed the beak of the gorget
  in the groove  of the  staff, the operator
  takes hold of the  latter instrument him-
  self; raises its handle from the right groin,
  wi that it may form nearly a  right angle
  with the body, and he stands up. " Before
  attempting to push  the  gorget onwards
  into the bladder, he should slide it back-
  wards and forwards,  with a wriggling
  motion,  that he may be sure its beak is in
  the groove of  the  staff".  The bringing
  forward  the handle of the latter instru-
  ment, so as to elevate its point, before in-
»• traducing the gorget into the bladder, is
  also of immense importance, for,  it is by
  this means, that the gorget,  is  introduced,
  along the groove of the staff in the axis
  of the bladder, the only direction, unat-
  tended with  risk of wounding the rec-
  tum.  In fact, the gorget should be intro-
  duced nearly in a direction, correspond-
  ing to a  line drawn from the  os coccygis
  to the umbilicus.
    As soon as the gorget is introduced, the
  staff" is to be withdrawn.  Some operators
  next pass the forceps,  along the  concave
  surface of the gorget, into  the bladder;
  while others, with every appearance of be-
  ing right, recommend the cutting gorget
  to be withdrawn immediately it has com-
  pleted the wound; for, then the bladder
  contracts violently, and its  fundus would
  be very apt to be cut, if the gorget were
  not withdrawn. This should be done in
  the same direction, in which it entered,
  pressing  it towards the right  side to pre-
  vent its making a second wound incoming
  [»it.  If the operator should prefer pass-
  ing the  Keeps into the bladder, along
  the gorget, the  latter instrument must be
  kept quite motionless, lest its sharp edge
  should do mischief;  and, at  all  events,
  immediately  the forceps  is in the blad-
  der, the  cutting gorget is to be with-
  drawn*
    Some  operators withdraw the  cutting
  [Jorge t, -and introduce a blunt  one  for the
  guidance of the forceps; a step certainly
  unnecessary,  as the latter instrument, will
  easily  pass, when the  incision into  the
  bladder is ample and direct, as it ought
  always to be.
    The operator has next to  grasp the
  stone with the blades of the forceps;  for
  which purpose,  he is not to expand the
  instrument, as  soon  as it has arrived in
  tlie  bladder;  but, he should  first  make
  use ot  the instrument as a kind of probe,
  lor ascertaining  the exact situation of the
  stone.   If this body  should  be lodged at
  the lower part ofthe bladder, just  behind
  its neck,  the operator is to  open the in-
 strument immediately over the stone, and,
 after depressing the blades a little, is to
 shut them, so as to  grasp it.  Certainly,
 it is much more scientific to use the for-
 ceps at first, merely to ascertain the posi-
 tion ofthe stone ; for, when this is known,
 he is much more able to grasp the extra-
 neous  body in a skilful  manner, than if
 he were to open the blades of the instru-
 ment  immediately  without   knowing
 where they ought  next to be placed, or
 when shut.  No man can doubt,  that the
 injury which the  bladder frequently suf-
 fers,  from rough, reiterated, awkward
 movements  of the forceps, is not  an un-
 common cause of such inflammation of this
 viscus, as too  often extends to  the peri-
 tonaeum, and occasions death. -
   When the  surgeon  cannot readily get
 hold of the stone  with  the forceps,  he
 should  introduce   his  fore and middle
, fingers into the rectum,  and raise the ex-
 traneous body  up,  when it may generally
 be easily grasped.   The stone should be
 held with  moderate firmness  to keep  it
 from slipping from the blades,  but, not
 so forcibly as  to  incur the  risk  of  its
 breaking.
   Sometimes,  the  extraction of the stone
 is attended with difficulty, owing to the
 operator having chanced  to grasp  it in a
 transverse  position, in  which  circum-
 stance, it is better  to try to change  its di-
 rection, or let  it go altogether, and take
 hold of it in another  manner.  When the
 stone is  so large,  that it cannot be ex-
 tracted from the wound, without violence
 and  laceration,  the  surgeon may  either
 break the stone  with a strong pair of for-
 ceps, with teeth constructed for the pur-
 pose ; or he may enlarge the  wound with
 a probe-pointed crooked bistourv,  intro
 duced  uuder the guidance of the forefin-
 ger of the left hand.  The  latter plan is
 generally the best ofthe two; for, break-
 ing  the  stone is an exceedingly unplea-
 sant circumstance, as  it creates such  a
 clanger of  calculous fragments remaining
 behind.
   However,  as nothing  can justify the
 exertion of force in  puliing out a stone, if
 the operator should be afraid of making
 the wound more ample, (its being already
 large and direct) he must break the stone,
 as above described.   As many ofthe frag.
 ments are then to be extracted with the
 common  lithotomy forceps,  as can be
 taken away in  this" method,  after which
 the  surgeon should introduce his finger,
 in order to feel, whether any pieces  of
 the stone still  remain behind.  Perhaps,
 some of these may  be most conveniently
 taken out  with  the scoop;  but, if they
 are very small,  it is best  to  inject  luke-
 warm water with moderate force into the 
182
LITHOTOMY.
wound, for the purpose of washing them
out.
  The stone should always be examined
immediately it is extracted; because,  its
appearance  conveys  some  information,
though not  positive, concerning the  ex-
istence of others.   If the stone is smooth
on one surface, the smoothness is gene-
rally-found to arise from the friction of
other stones still  in  the bladder; but,
when it is uniformly rough, it  is  a pre-
sumptive sign,  that there is no other one
remaining  behind.   In  every   instance,
however,  the  surgeon should introduce
his forefinger, tor the purpose of examin-
ing ;  for, it would be  an inexcusable ne-
glect to put the patient to bed,  with an-
other stone in his bladder.
  After the  operation, a simple pledget
should be laid  on the wound, and sup-
ported with a  T  bandage;  the patient
should lie in bed on  bis back,  with his
thighs closed; folded cloths should be
laid under him to receive the urine ;  and
a large opiate  administered, as after all
grand operations.

 OF SOME  PARTICULAR  METHODS  AND IN-
              STRUMENTS.

  M. Foubert,  a very eminent surgeon at
Paris, devised and practised a plan of  his
own,  which however, has not been con-
sidered by others,  as worthy of being imi-
tated.  The patient,  having retained his
urine,  so  as to distend  his  bladder, an
assistant, with a convenient bolster, presses
the abdomen a little below the navel, in
such a manner, that by pushing tlie blad-
der forwards, he  may make' that part of
it  protuberate, which lies between  the
neck and  the  ureter.   The  operator, at
the same time,  introduces the fore-finger
ot his left hand up the rectum, and draw-
ing it down towards  the right  buttock,
pushes in a trocar on  the left side of* the
perinaeum, near the great tuberosity of
the ischium, and about an inch above the
anus.  Then  the trocar is to be carried
on parallel to the rectum, exactly between
the erector  penis and accelerator urinae
muscles, so as to enter the bladder on one
side of its neck.  As soon as the bladder
is wounded, the operator withdraws  his
fore-finger from the anus.
  In the upper part of the cannula of the
trocar, there is a groove, the use of which
is  to allow some urine to escape,  imme-
diately the instrument enters the bladder,
that  the trocar  may not be pushed  in any
further; but, it£ principal use is  for guid-
ing the incision.  As  soon as the urine
began  to flow, Foubert, retracting the
trocar a  little, without  drawing it quite
out of the cannula,  introduced  the point
of a slender knife  into the groove in the
cannula; and, by the •guidance oF  th.s
groove, he ran  it onwards into the bind.
der,  and was aware of  the knife having
actually entered this viscus, by the  urine
flowing still  more  freely   Then raising
the knife  from the  groove, he made his
incision, about an  inch  and a half in
length, through the neck of the bladder,
by moving the knife from  that point, at
which it had entered upwards towards
the pubes.  And, finally, by moving the
handle  more  largely,  than  the point of
the knife, he opened the outer part of the
wound to whatever extent the size of the
stone seemed to require, and then,  with-
drawing the knife,  he introduced a blunt
gorget to guide the forceps.
  An effort was made by Thomas to im-
prove this method ; but,  he failed ; and
it was  never much adopted.  The inabi-
lity of many bladders to allow being dis-
tended, is  an insuperable objection j for,
without this, the trocar is liable to pass
between the bladder  and rectum,  and
even  through the bladder into the pelvis.
{Memoires de I'Acad, tie Chir. 663, vol. 1.
Le Dran's Paraliele.  Sharp's Critical In-
quiry.  J BelPs Principles, vol. 2.)
  About the middle of the  last century,
Frere Cosme constructed for lithotomy, a
knife, concealed in  a sheath, out of which
it started  on  touching a  lever.   This
instrument is entitled  to  particular at-
tention,  because  it is still used in seve-
ral parts of the continent, and even in
this country, by the surgeons of the West-
minster  Hospital.   Frere Cosme  made
the same external incisions, as in the la-
teral  operation, and, after dividing the
membranous part of the  urethra,  he in-
serted  into the groove of the  staff the
point of" his lithotome,  or bistowrie cachee,
and pushed it into the bladder, after which
the staff'  was  withdrawn.  The edge of
the knife was then  turned sideways, and
the lever in the handle being touched, the
blade started from  its sheath, and,1 being
drawn out, divided the  prostate and neck
of the bladder. The  danger of wound-
ing  the pudic artery;  of injuring the
bladder in more places than one,  if col-
lapsed ; and of cutting the rectum, if the *
edge ofthe instrument should be inclined
too much downward ; are the objections,
which have  been urged against tiie em-
ployment ofthe lithotome of Frere Cosme.
The second is the only one, that has much
validity, and even  it might be done away,
by not introducing the instrument too far,
and yet carrying on the incision just as
far laterally, as would  be the effect  of
having more of the instrument to with-
draw from the  bladder.   If this were not
done, the wound would be  too small to 
LITHOTOMY.                              183
  admit of the stone being extracted, with-
  out laceration.
    Le  Cat, a surgeon, of Rouen, in Nor-
  mandy, devised  a mode  of  lithotomy,
  which would be too absurd to be describ-
  ed, were  it not so much renowned.  He
  thought the neck of the bladder might be
  dilated, like that of the wound, and his
  operation  was  deformed with all  the
  cruelty of the Marian method, and every
  error attendant on the infant state of the
  lateral operation  He first  introduced  a
  long big staff'; he cut forward with a com-
  mon scalpel, through the skin and fat, till
  he could distinguish the bulb, tlie  naked
  urethra, and the prostate gland.  Second-
  ly, with  another knife, called  urethro-
  tome, Iiaving a groove  on one  side,  he
  opened the urethra, just before the pro-
  state,  and, fixing the urethrotome  in the
 , groove of the staff", and holding it steady,
  rose from the kneeling posture, in  which
  he  performed  the  outward  incision.—
  Thirdly, holding  the urethrotome  in the
  left hand, he  passes  another knife, the
  cystotome, along the groove of the urethro-
  tome, and the beak of the cystotome being
  lodged in the groove  of  the urethrotome,
  it was pushed forwards,  through the sub-
  stance of the prostate gland into the blad-
  der.   Fourthly, drawing the cystotome a
  little»backwards, he gives the staff to  an
  assistant  to  hold steadily,  and  lifting
  a  blunt gorget  in  the right hand,  he
  places the beak of it in the groove  of the
  cystotome, and  runs  it onwards,  till  it
  glides from the groove of the cystotome,
  along the groove of  the staff  into the
  bladder.  Then, true  to the principles of
  the apparatus  major, and,  never forget-
  ting his own peculiar theory, little incision,
  and much dilatation, he forced his fingers
  along the gorget, dilated the  neck  of the
  bladder, and so made way for the forceps.
  (J. Bell's Principles,  Vol. 2.)
    In  1741, Le Dran described an  opera-
  tion, the introduction of which has been
  cla.med by  several  since his time.  A
  staff being introduced, and two assistants
  keeping open the patient's knees, while a
  third stands on one side of him on a chair,
  (Le Dran  says,) «• I  then  raise up the
  scrotum,  and directing the last assistant
r to support  it with both hands,  so as to
  avoid bruising  it, by  pressing it  either
  against the staff, or the os pubis, 1  place
  his two forefingers on each side of the
  part,  where the incision is to be  made;
  one of the fingers being laid exactly along
  that branch  of thj| ischium, which rises
  towards the pubes, and  the  other pres-
  sed upon the  raphe,  that  the skin may
  be kept '..xed and tight.  While  I thus
  place the fingers  of the assistant, who
  supports tiie scrotum, I  still keep hold of
the handle of the staff, and direct it so as
to form a right angle with the patient's
body;  at  the  same  time,  taking  care,
that the end of it is in the bladder.  This
position is the  more essential, as all  the
other instruments are  to  be conducted
along the groove of  this   If tlie handle
of the  staff  were kept inclined towards
tho  belly, the end of it would come out
of the bladder,  and the gorget,  missing
its guide, would slip between that and the
rectum.
  " The staff being rightly placed, I take
the knife  from  the assistant,  who  holds
the  instruments,  and  put  it into  my
mouth; then pressing the beak of the staff*
against'the rectum,  I f el  the curvature
of  it  through the  perinaeum.  The in-
cision  ought to terminate, an iuch  and
a half,  below where we  feel the bottom of
the  curvature.  If we  do not carry  this
incision sufficiently  low, it may happen
not to be of a size to allow the extraction
of a large stone, and  might lay us under
the necessity of extending it further after-
wards,  for the .skin will  not lacerate here,
nor easily give way for the passage ofthe
Stone.  I therefore begin the incision from
the lower part of the os pubis, continuing
it down to the place, that I before direct-
ed for its-termination ; after which I pass
the point of the knife into the groove of
the staff', and cutting from below upwards,
without taking the point out ofthe groove,
I  open tiie anterior part of  the urethra,
as  far as  the  incision, that is in  the
skin.
   " The  beak of the  staff, which   was
pressed upon the rectum, must now be
raised  and pressed against the os pubis.
At the  same  time, 1  turn  the handle to-
wards  the right groin,  that  the  groove,
which is at the  beak of  the staff, may face
the space, between the anus and the tu-
berculum ischii on  the left side.  Then
carrying the point of the knife down  the
groove, I slide it along the beak,  turning
the edge, that it may face the space, be-
tween  the  anus and  tuberosity of  the
ischium.  By this incision, I  exactly di-
vide the bulb of the urethra, and by do-
ing this on its side, \ve  are sure to  avoid
wounding the rectum, which, for want of
.this precaution, has  been often cut. This
first incision being  made, I again  pass
the point .of the knife into the curvature
of the staff" to  the part,  where  it bears
against the perinjeum, and direct it to be
held there by the assistant,  who supports
the  scrotum.   This  done,  I  take a large
director,  the end of which is  made with a
beak, like that of a gorget, and conveying
this beak, upon the blade of the knife,
into the groove of tlie staff, I draw the
knife out.  I then slide the  beak of this 
184                             LITHOTOMY.
director, along the groove of \he  staff',
into the bladder, and 1 withdraw the staff
by  turning  the handle  towards  the pa-
tient's  belly.   The  following  circum-
stances will sufficiently  satisfy  us, that
the director is introduced into  the blad-
der ;  first, if it 6trikes against the end of
the staff, which is closed; secondly, if
the urine runs along  the groove. I next
feel tor the stone with this director, and,
having found it, endeavour to distinguish
its size and surface,  in order  to  make
choice of a proper pair  of forceps;  that
is, one of a stronger,  or  weaker make, or
of a large or small size, agreeably to that
of the stone;  after  which I  turn the
groove, towards the space, between the
anus and tuberosity of the ischium, and,
resting it there,  convey a bistoury  along
the groove,  the blade of which is half an
inch broad,  and about three  quarters of
an inch long.   I  continue the  incision,
made by the knife in the urethra, and en-
tirely divide the prostate gland laterally,
as also the orifice of the bladder; and, I
am very certain, that the introducing the
use of these two instruments, which are not
employed by other lithotomists,  does not
prolong the operation a quarter  of  a mi-
nute,  but,  rather shortens the time, both
by facilitating the dilatation,  that  is af-
terwards to be made with the finger, and
by rendering the extraction of the  stone
more  easy.  The  bistoury being with-
drawn,  the groove of the director serves
to guide the gorget into the bladder.  I
then introduce  my forefinger  along the
gorget  (which is now easily done, as the
urethra and prostate, being divided,  do
not oppose its entrance) and with it I di-
late the passage for the  stone,  in propor-
tion to the size,  of which 1 discover it to
be.  This dilatation being made, I with-
draw  my finger, and  use the proper for-
ceps "   (Le Dran's  Operations, edit. 6,
1784, London.)
  The high operation, which we have al-
ready described, was introduced by  Fran-
co, in 1561, and was again   revived in
1658,  by Frere Cosme,  with  what were
supposed to be some improvements.  Tlie
latter  proposed  to open the bladder in
perinaeo, and then, through an  opening
made just above  the  pubis,  he  intro-
duced a ssalpel with a button-point, with
which he slit up,  for  an inch or  two, the
linea  alba, the knob on the  end of the
knife  pushing aside   the  peritoneum.
After this, he introduced, by the aperture
in perinaeo, a staff,  with which he pro-
jected the bladder through the  opening,
between the recti muscles: this done, he
cut  into the front of  the bladder, and
either with his finger and thumb, or with
a pair of forceps, he took out the  stone.
In this way, he extracted a calculus from
the bladder,  weighing 2\ ounces.  Wtrr
it not for the danger attendant on the
double incision into the bladder, and the
protraction  of the operation by the dis-
section  about the perinaeum,  this plan
might, with  propriety, be adopted.  In-
deed, as modified by Deschamps, who, in
place of  the  puncture in perinaeo, perfo-
rates the bladder from the Tectum, it has
met with the approbation  of Dr. Thom-
son, of  Edinburgh, who considers tiiis,
on particular occasions,  to  be the most
advisable mode  of operating.  It is evi-
dent, however, that if the  bladder  be
thickened and indurated,  it will be im-
possible  to raise it above the pubes with
the cannula,  and, consequently, the plan
is only admissible when we have reason
to suppose that the stone is too large to
be removed from the perinaeum, and the
bladder is healthy.   The puncture from
the rectum is simple,  attended with no
increase of danger, allows  the bladder to
be elevated by the cannula, and secures a
depending outlet for the urine.  We avoid
thus the necessity of any discha- ge by the
wound above the pubes, we run no risk
of the urine  insinuating  itself into the
cellular membrane;  no inflammation is
excited; no sinuses are formed.  (Burns,
in Edinb. Surg. Journal, No. 13.)
  The danger of the beak  of the gorget
slipping out of the groove of the staff, is
one of the chief objections uiged against
the employment of the first of these in-
struments. To obviate this, Sir Charles
Blicke had the groove of the  staff, and
the beak of  the  gorget, so constructed
that they locked into each other, and con-
tinued fixed till near the extremity of tlie
staff'. The contrivance, though plausible
and  ingenious, is not much used; the
point of contact of the beak and body of
the  instrument  is mecessarily  so  small,
that it is liable to break.   It is allowed,
however,  that this objection might be re-
moved; but  another  one  is still urged,
viz. the beak and groove catching on each
other, so as to resist the efforts made to
introduce the gorget  into the bladder.
Every operator knows, that much of the
safety of the lateral  operation,  as. per-
formed at present, depends on the ease \
with which the beak of the gorget  slides
along the groove of the  staff.  Le Cat,
in 1747,  is said  to have devised a similar
instrument.
   Some operators seem to have a good
deal  of  trouble in  dissecting into  the
groove of the staff'.   Sir James Earle in-
vented an instrument to render this more
eas5-.' It consists of a  short sUjT, with an
open groove, connec ed by a hinge, with
the  handle  of another staff of the usual 
LITHOTOMY.                     ,        185
size,  shape, curvature, and length, which
may be called the long staff.  The hinge,
by means of a pin, is capable of being dis-
jointed at  pleasure.,  The  short  staff is
sufficiently curved  to  go over tiie penis
and scrotum,  and long enough to reach
to that part of the long staff' which is just
below the beginning of  its  curvature.
The end of the  short  staff, made some-
what  like  a pen, with the sides  sharp-
ened  and  finely pointed, is  adapted to
shut into the groove of the long staff, and
its cutting edges are defended from being
injured by  a proper receptacle  which is
prepared for it in the groove  of the long
staff   When the instrument is shut, the
groove ofthe short staff leads into that of
the long one, so  as to form  one connected
and continued groove.  The short staff' is
rendered steady by the segment of an
arch projecting from the long one through
it.
   The long staff, separated from the short
one, is first introduced in the usual man-
ner, and,  the  stone having  been felt, the
short staff is to be put on the other at the
hinge.  The incision is then to  be made
in the usual  manner, through tlie skin
and cellular membrane, and a second  in-
cision through the muscles, so as nearly
to lay bare the  urethra,   The operator
then being perfectly convinced, that tiie
extremity of the long staff is sufficiently
within the bladder, must bring the end
of  the short staff down,  and press  it
against the urethra, which it will readily
pierce,  and pass into tlie  cavity prepared
for it  in the groove of the long staff. The
two staffs being  now firmly held together
by the operator's left hand, nothing  re-
mains to be  done, except  applying the
beak  of the gorget, to the groove of the
short  staff, and  push it on till  it  be  re-
ceived in the groove of the long one; and
if this latter be  made with a contracted
  Soove, it will just enter where the con-
  action begins,  and thus must be safely
conducted into the bladder.  {Earle on  the
Stone,- Appendix;  Edit. 2, 1796;)  Des-
champs describes an instrument,  invent-
ed by Jarda,  a  surgeon  of Montpelier,
which bears  a  resemblance to  Earle's
double staff, but was more complicated,
being designed  to support the scrotum,
and also press  the rectum out of the way.
  With respect to  the method of using
the double staff",  would it be proper, im-
mediately after piercing the urethra with
the point of the short staff,  to plunge tlie
gorget into the bladder,  without  having
previously divided with a knife the mem-
branous part of the urethra ? The reader
will hardly approve of this plan, what-
ever opinion he may entertain of the uti-
lity of the  instrument.
    Vol. II
  The  late Mr. Dease, of Dublin, and
Mr. Muhy of Glasgow, considering that
the gorget was  more apt to slip from the
staff in  consequence of the latter being
curved, and that its beak never slips from
the groove  of  the staff in operating on
women,  proposed, like Le Dran,  to con-
vert the male  into the  female urethra.
They introduce, as usual, a curved grooved
staff' into the bladder, make the common
incision, and open tiie  membranous part
of  the  urethra;  but,  instead of intro-
ducing a gorget on the  curved staff, they
conduct along the groove  a  female one
into the bladder,  and immediately with-
draw the odier.  The  gorget is then in-
troduced.  This, method  certainly  re-
moves the dangej? arising  from the slip-
ping of the latter instrument.

LITHOTOMT,  AS  PBHFOBMED WITH A KXIFE,
  INSTEAD OF A  CUTTING GORGET, BY SEVE-
  RAL OF THE MOHKRXS.

  We have already described,  how Frere
Jacques and Cheselden used to operate
with a knife, without any cutting gorget,
in the early state  of the lateral operation.
The success, which attended the  excel-
lent practice of the latter surgeon, cer-
tainly far exceeds what attends the prer
sent employment of the gorget, for, out of
52 patients, whom he cut successively for
the stone, he only lost two;  and  out of
213, of all ages,  constitutions, &c. only
20.   These facts are strongly in  favour
of abandoning the use of tiie gorget, and
doing its office with a knife.
  The objections'to the gorget are nume-
rous and well founded.   In the hands of
many skilful operators, its beak has slip-
ped out of the groove of the staff, and the
instrument has been driven either between
the rectum and the bladder, or into the
intestine instead of the latter viscus.   Sir
James   Earle remarks:  " I  have more
than once known a gorget, though passed
in the right direction,  pushed on  so far,
and with such violence,  as to  go through
the opposite side ofthe bladder."  Brom-
field, even  when  operating with a blunt
gorget,  burst through the bladder and pe-
ritonaeum, so that the  abdominal  viscera
came out ofthe wound.  (F. 270.) I knew of
one instance in which the gorget, slipping
from the  staffi  completely severed the
urethra from the  bladder; the stone was
not taken out, and the  child-died.
  We  will  suppose, however, that the
preceding dangers of the gorget are sur-
mounted, as they certainly may  be,  by
particular dexterity, seconded by the con-
fidence of experience.   The gorget is  in-
troduced, but whatever kind of one has
been used, the wound is never sufficiently
    A a 
189                             L1T1I0T0.ATV.
 large for the easy passage of any stone,
 except one below the ordinary size. Cam-
 per has noticed this tact:  " Hawkensius
 solo conductore, cujus maigo dexter in
 aciem assurgit, idem praestat: omnes pia-
 gam dilatant, ut calculum extrahant:  dila-
 cerentur igitur semper vesicx ostium et pro-
 stata." (P.  114.)  Dease says:  " In  all
 the trials that I have  made with the gor-
 get on the  dead subject, I have never
 found the  opening into the bladder suffi-
 ciently large for the extraction of a stone
 of a middling size,  without a considerable
 laceration of the parts. I have frequent-
 ly taken  the largest-sized  gorget,  and
 could not find, in the adult subject, I ever
 entirely divided the prostate gland,  if it
 was any  way  large;  End in  the opera-
 tions that were performed here on the
 living subject, if the stone was large,  the
 extraction was painfully tedious, and  ef-
 fected with great difficulty, and,  in some
 cases, not at all."            '
   I shall dismiss this part of the subject
 with referring the reader to the  spirited
 and correct remarks on the objections  to
 the gorget in Mr. John Bell's Principles,
 Vol. 2, Part 2.
   The latter author recommends the ex-
 ternal incision, in a large man,  to com-
 mence about an inch behind the scrotum,
 and to be carried downwards three inches
 and a half, midway  between the anus and
 tuberosity  of the ischium.  The fingers
 ofthe left hand, which at first kept the
 skin tense, are now applied to other  pur-
 poses.  The  fore finger now  guides the
 knife, and the  operator proceeds  to dis-
 sect through fat  and  cellular  substance,
 and muscular and ligamentous fibres, till
 the  wound is free and open, till all sense
 of stricture is gone; for it is only by feel-
 ing opposition and stricture, that  we re-
 cognize  the transverse muscle   When
 this hollow is fairly laid open, the exter-
 nal incision, which relates merely to the free
 extraction ofthe stone,  is completed.  If it
 were the surgeon's design to operate only
 with the knife, he would  now  push  his
 fingers deeply into the wound, and, by the
 help of the fore-finger, dissect from the
 urethra along the body of the gland, till  he
 distinguished its thickness and solidity,
 and reached its back part.  Then plung-
 ing his  knife through  the posterior por-
 tion of the gland, and settling it  in the
 groove ofthe staff, he would draw it firm-
 ly and steadily towards him, at the same
 time pressing it into the groove  of  this
 instrument, and then the free discharge
of the urine,  assuring  him that the  pro-
 state and neck of tlie bladder were divid-
 ed, he would lay aside his knife, pass the
 left  fore-finger into the  bladder, with-
 draw the staff, and introduce the forceps.,
 {John  Bell,p. 197.) .
   Mr. Charles  Bell describes the  follow
 ing method of  operating with a knife, in-
 stead ot a gorget.   A staff' grooved on the
 right side,, a scalpel with a straight back,
 and the common lithotomy  forceps,  are
 the indispensable  instruments   The staff'
 is kept m the centre,  and well home  into
 the bladder. The surgeon making his in-
 cision under the arch of the pubes,  and
 by the side of  the anus, carries it  deeper
 towards the  face ot  the prostate  gland:
 cutting near to the staff", but yet not cut-
 ting into it, and avoiding  the rectum  by
 pressing it down with the finger.  Now
 cai ry ing the knife along  the staff',  the
 prostate gland  is felt. The  point of  the
 knife is run somewhat obliquely into the
 urethra, and into the lateral groove of
 the staflj just  before the  prostate gland.
 It is run on, until the urine  flows." The
 fore-finger  follows the  knife, and it is
 slipped along the back of it, until it is in
 the bladder.   Having carried the fore-
 finger into the  bladder, it is kept there,
 and the  knife  is  withdrawn.  Then  the
 forceps, directed by the finger, are intro-
 duced.  (C. Bell's Operative Surgery,  IV
 l,p. 361.)
   Mr. Allan Burns, of Glasgow,  recom-,
 mends the following  plan:  " The plan,
 says  he, introduced  by  Cheselden,-and
 revived by Mr.  J. Bell, 1 would assume,
 as  tlie basis  of the operation; hut still,
 along  with their  mode,  I would blend
 that of Mr. Dease, by which, I imagine,
 we may overcome  some  of the disadvan-
 tages  attendant on each considered indi-
 vidually.
   " For more than twelve  months, I have
 been in  the habit of shewing such an
 operation, which is as simple in its per-
 formance, as the  one in  general  use, is
 attended with  less danger to the patient,
 permits  of an incision varying in size, ac-
 cording  to the  wish of the operator,  and
 completely prevents injury of the rectum,
 or pudic artery. -To  perform  this oper-
 ation,  I introduce into the urethra a com-
 mon curved staff', then make the usual in-
 cision  into the perinaeum,  divide fully
 and freely the levator ani,  so as to expose
 the whole extent of the membranous pari
 of the urethra,  the complete extent of the
 prostate gland, and a portion of the side
 of the neck of the bladder.   When  this
Wrt of the operation is  finished,  I open
 the membranous part  of the urethra,  and
 introduce through the slit, a straight or
 female staff', with  which I  feel the stone,
 and then withdraw the curved staff. This
 done, I grasp the handle ofthe staff firm-
 ly in my  left hand, and with  the right hw
V 
LITHOTOMY.
187
hold of the knife.  Having ascertained,
that the two instruments  are in fair con-
tact, I rest the one hand upon the other,
pressing  them  together, and  then by a
steady extraction, 1 pull out the knife and
staff together, which is preferable to draw-
ing the knife along  tiie staff',  it prevents
the risk of the one slipping  from  the
other ;  it guards the bulb of the urethra,
and every  other  part  from injury; for,
between them and the cutting instrument,
the staff is interposed;" &c.   " When in-
troducing the knife, the side of the blade
must be laid  fiat along the fore-finger  of
the right hand, which is to project a little
beyond the point. In this state the finger
and knife  are to enter the wound, oppo-
site the tuber-ischii; but, in  proportion
as they pass along,  they are to be inclin-
ed forward, till at last, with the point of i
the finger, the staff >s  to be felt through
the coats of the bladder, a little beyond
the prostate, and rather  higher than the
orifice of  the urethra.  Here the knife is
to be pushed, with  the  finger,  through
the bladder, and when the point is fairly
fixed in the groove  of the staff the oper-
ation is to  be finished by the steady ex-
traction  of both  instruments."  (Allan
Burns, in Edinburgh Surgical Journal, No.
13.)
   The knife of Cheselden does  not  re-
quire so much violence to divide the parts
as the gorget does; cannot slip in some
instances  before, in others  behind the
bladder;  and it will make a wound suffi-
ciently  ample for the  easy extraction of
the  stone, without the  least laceration.
The possibility of its wounding the rec-
tum,  Mr.  Thomson thinks might be  ob-
viated by employing it as follows :  " Af-
ter having made the  external incisions,
and divided the membranous part of the
urethra, in the way that is usually done
for the introduction of the beak of  the
gorget, a straight-grooved- staff is to be
introduced into the g-roove of the curved
staff, and  pushed along it into the  blad-
der.  The curved staff' is then to be with-
drawn,  and the surgeon, laying  hold of
the handle of the straight staff with his
left hand, and turning  the  groove  up-
wards and a little outwards, presses the
back of It downwards towards the right
tuber ischii, and holds it steadily in that
position.  The point of a straight-backed
scalpel -being now  introduced  into  the
groove ofthe staff",  with its cutting edge
inclined upwards and a  little outwards,
is to be pushed gently forwards into the
bladder.  The  size of the scalpel need
only be such as will make a wound in the
prostate gland and  neck of the bladder,
sufficiently large to admit the fore-finger
of the  left hand.  The scalpel bejng re-
moved, this finger is  to be introduced
into  the bladder,  through  the  wound
which has been made,  and the staff may
then be withdrawn.  With the finger the
surgeon endeavours to  ascertain the size
and situation of the  stone.  If,  after this
examination,  he judges  the  incision in
the neck of the bladder  to be  too small
for the easy extraction of  the  stone, he
next introduces into the bladder a straight
probe-pointed bistoury, with its  side close
to the fore part of his finger,  and its cut-
ting edge upwards. By turning this edge
towards the left side, and by  keeping the
point  of his fiftger always  beyond the
point of  the bistoury,  he .may  safely  di-
vide; in the direction of  the  first incision
as much of the prostate gland, and  neck
of the  bladder, as he shall deem necessa-
ry."  See Observations  on Lithotomy, &c.
with a  Proposal for aNew Manner of Cut-
ting for the Stone, by J. Thomson, M. D.
one ofthe Surgeons ofthe Royal  Infirmary,
&c. Edinb.  1808.   In  this  small  work,
the reader will  find  additional particu-
lars.
   Mr.  Allan, who is a  strenuous advocate
for using the knife instead of the gorget,
directs us, after laying bare the urethra,
and  bringing  the staff'  so as  to form a
right angle with  the  patient's body, to
feel that the instrument is fairly lodged
in the  bladder.   The  operator is to use
the fore-finger of his  left hand as  a  di-
rector in feeling  for  the groove in the
staff, and in distinguishing the prostate
gland ; and, with this finger, he is to de-
press the rectum, and  direct the deeper
part of his dissection.   " Feeling* the
gland, with the point  of the fore-finger
of the left hand,  and  the groove of the
staff in the upper part  of the wound, the
assistant is  desired  to steady  his  hand,
and the operator, holding his knife as he
does a writing pen, his fingers an inch
and a half from  the  point,  turns up its
edge  towards  the staff", and strikes its
point  through the  membranous part  of
the urethra into its  groove,  half an inch
before the prostate gland.  He  now turns
the back of the knife to  the staff", slides
it a little backwards and forwards in the
groove, that he may be sure he has fairly
entered; then shifts the  fore-finger, with
which lie  guides the  incision, places  it
under the  knife,  and  carries always  be-
fore the point  of it, to prevent tiie rectum
being wounded;  he then  lateralizes the
knife,  enters  the substance of the pro-
state, is conscious of running the scalpel
through its  solid and fleshy  substance,
and judges, by the finger, of the extent of
the incision, which  he now makes.   The
urine  flows out; he  slips in  the finger
into the opening, withdraws the scalpel, 
188
LITHOTOMY
and gives  it to an  assistant, who hands
him the forceps, which he passes into the
bladder, using the  fore-finger of his  left
hand, which is still within the wound, as
a conductor.   The  forceps  instantly en-
counter the staff, which serves to conduct
them safely into the  bladder, while  the
finger guides them through the wound;"
&c.   (Allan on Lithotomy,  p.  48, Edinb.
1808.)
  I leave the reader to judge,  which of
the foregoing modes of operating with a
knife,  claims  the  preference.    Perhaps
Cheselden's manner, which is  also  Mr.
John Bell's, is  as deserving of recommen-
dation as any.
  Mr. Lawrence has, very obligingly, al-
lowed me to insert  in this  work the fol-
lowing case, in which he  performed li-
thotomy with a common knife, and with-
out any  gorget.  He describes the me-
thod  which he  took, as follows:  " On
the first of December, 1808, I performed
the operation  of lithotomy on  Mr.  Ri-
chard Cooper,  aged 63, in  the presence
of Mr. Crowther,  surgeon  to Bridewell
and  Bethlem  Hospitals,  Air.  Barnes, a
pupil of  St.   Bartholomew's,  and some
other gentlemen.  The patient  was very
fat, particularly  about the  nates and pe-
rinaeum, so that my  tore-finger was buried
beyond the middle joint before I had laid
bare the groove ofthe staff, which I made
a point of doing behind  the bulb of the
urethra, having  always   considered  any
division ofthe bulb to be perfectly useless,
and  even  prejudicial.   I continued the
incision through the prostate, and neck
ofthe bladder, with the same instrument
that was used  for making  the  first  cut,
(a common scalpel,) carried horizontally,
with its back in  the groove of the staff,
until it reached the bladder,  and then
moved  obliquely  outwards  and  down-
wards, so  as to obtain a cut of the requi-
site size in the neck of that viscus.  The
quantity of fat was so considerable, that
I could barely feel the stone with the end
of my fore-finger pushed as high  up as
possible.  I employed the left fore-finger
as a conductor for the forceps, and  ex-
tracted, without the least violence, a stone
measuring five inches in its greatest, and
four in its least, circumference.  Xo un-
pleasant symptom followed the operation,
not the slightest mark  of inflammation,
nor  the least pain, nor tension of the ab-
domen.
  " I have publicly demonstrated to the
pupils of  St. Bartholomew's the mode of
operating with an  ordinary knife,  and
have repeatedly practised  it in  the dead
subject, without  ever experiencing  the
slightest difficulty  in making an open-
ing of any extent that  I wished  into the
bladder.*"                 .
  [It  is not  my intention  in this place
to decide whether the gorget ought to
be renounced in the operation of litho-
tomy and  the scalpel substituted or not;
but I wish  to declare  my  opinion, that
many of  the  accidents which  have oc-
curred  in  this  operation are owing to
the construction of the gorget, the beak
of which prevents the  possibility of ha-
ving an  edge, perfectly  keen,  contigu-
ous to the  beak.  The consequences of
the gorget being dull  at this place,  are,
first,  That the  urethra  is sometimes
thrown into  folds  before  the  blade  of
the instrument, and in this manner  the
beak  is forced out of  the groove in the
staff".   Secondly,  When the  gorget en-
ters tlie  bladder,  it enters  with a jirk
and with more violence  than  the sur-
geon  intended.  A gorget has been con:
structed by Dr. Physlck, in  which this
objection  is entirely obviated, by having
the blade  separable from the beak.  This
instrument is described in the Med. Mu-
seum,  vol. 1 ]

         LITHOTOMY IX WOMEN.

  Women suffer much  less from the stone
than men, and far less frequently stand in
need of the operation of lithotomy.  It is
not, however, that their urine will not so
readily produce the concretions, which
are termed urinary calculi.   The reason
is altogether owing to the shortness, large-
ness,  and very dilatable nature of the fe-
male  urethra; circumstances,  which in
general render the expulsion of the stone
with the urine almost a  matter of certainty.
The records of surgery present us with
numerous instances, where calculi of vast
size  have  been  spontaneously voided
through the meatus urinarius, either sud-
denly without pain,  or after more or less
time  and  suffering.   Heister mentions
several well authenticated examples of
this kind.  Middleton has also related a
case, where a stone, weighing four ounces,
was expelled  in a fit  of coughing, after
lodging in  the passage a week.  Collot
speaks of another instance, where a stone
about as large as a goose's egg, after lying
in  the meatus urinarius  seven  or  eight
days,  and causing a  retention  of urine,
was voided in a paroxysm of pain.  A re-
markable case is related by Dr. Molineux
  • The above patient afterwards died in
a kind of fit; but to all appearances, from
a cause, which had id connexion with the
operation! 
LITHOTOMY.
189
in the early part of the Philosophical
Transactions : a woman voided a  stone,
" the circumference of which measured
the longest way  seven  inches and six-
lenths, and round about, where  it was
thickest five inches  and three-quarters;
its  weight near two ounces  and a-half
troy.
  Sometimes, after the passage of large
calculi, the patient has been afflicted with
an incontinence of urine; but, in general,
this grievance lasts only a short time.
 • The naturally large size and dilatable
nature of the female urethra, have sug-
gested the plan of endeavouring to expand
this passage by various means, so that a
stone in  the bladder may be taken out
with  a pair of forceps, without  having
occasion to employ  any cutting  instru-
ment whatsoever.  This metliod was pro-
posed by Douglas nearly a century  ago,
who  not  only  recommended the use of
sponge for the purpose, but also dried
gentian root, as being more gradual in its ex-
pansion, and better adapted  to the object.
   Mr Broinfield has published the case
of a young girl, in whom he effected the
 necessary dilatation  by  introducing into
 the  meatus urinarius,  the  appendicula
 cocci of .a  small  animal  in a collapsed
 state, and  then filling  it with water  by
 means of a syringe.  The  piece of gut,
 thus distended, was drawn out, in propor-
 tion as the cervix vesicae opened,  and, in
 a few hours, the dilatation  was so far ac-
 complished, that the calculus had room to
 pass out.  (See Chirurgical Obs. and Cases,
  Vol. 2, p. 276.)
    Mr. Thomas very recently- met with a
 case, in which, after dilating the meatus
  urinarius with sponge tents he succeeded
  in  extracting  an  earpicker which lay
  across the neck of the bladder.  The pas-
 sage was so much enlarged, that the left
  fore-finger  was most easily  introduced,
  and  (says this gentleman)  " I believe had
  the case required it, both thumb and fin-
  ger would  have passed into the  bladder,
  without the smallest difficulty." After ad-
  verting to  this, and other  facts,  proving
  the ease, with which the female  urethra
  canrbe  dilated, Mr.  Thomas  remarks:
  " If these relations can be credited, and
  there is no reason why they should not, I
  can hardly conceive any case, in a young
  and healthy female subject, and where
  the bladder is free from disease,  where a
  very large stone may  not  be extracted,
  without the use of  any other instrument,
  than the forceps,  the urethra having first
  been sufficiently dilated by  means of the
  sponge tents.  For this purpose, the blades
  of the forceps need not be so  thick and
  strong, :xi those commonly employed. (See
Medico Chirurgical Transactions, Vol. 1, p.
123—129.)
  Some surgeons  have extracted stones
from the female  bladder in the following
manner:  the patient having been placed
in the position commonly adopted in the
lateral operation, a straight staff, with a
blunt end, is introduced into the  bladdjgr,
through the meatus urinarius.  The anr.
geon then passes along the groove of the
instrument  the  beak of a blunt gorget,
which instrument becoming wider towards
the handle, effects a part of the necessary
dilatation.  The staff' being withdrawn,  \
and the handle of the gorget  taken hold
of with the left,hand, the right fore-finger
with  the nail turned downwards, is now
introduced slowly along the concavity of
the instrument.  When the urethra and
neck of the bladder have thus been sufiir
 ciently dilated,  the finger  is withdrawn,
and a small pair oi' forceps passed into
 the bladder. The gorget is now removed,
 and the stone taken hold of, and extract-
 ed.  (See Sabatier s Medccine Operatoire,
 torn. 2. p. 103.)
   Notwithstanding these  favourable ac-
 counts ofthe practice of dilating the fe-
 male urethra, for the purpose of renloving
 calculi from the bladder, tlie generality of
 surgeons prefer the  plan of  making  an
 incision.  It is certain,  that some patients
 have found the method  insufferably te-
 dious and painful.  But  the strongest ob-
 jection to the practice has arisen from the
 incontinence of urine, which occasional-
 ly follows  any  great  distention  of the
 urethra and neck of the bladder.  Mr.
 Thomas believes, however, that this un-
 pleasant symptom is quite as often a con-
 sequence ofthe operation of lithotomy, as
 now usually performed.   (.Medico  Chirur-
 gical Transactions, Vol. 1, p. 127 )
    Lithotomy on females is much moie easy
 of execution, and less dangerous than the
 same operation  on the male  subject.   It
 may be done in various ways ; but, the sur-
 geons of the present time constantly follow
 the mode of making the requisite opening
 by dividing the urethra and  neck of the
 bladder.   A straight staff,  or director, is
 introduced through the meatus urinarius;
 the groove is turned obliquely downwards
 and  outwards, in a direction parallel to the
 ramus of the left os pubis ; and a gorget,
 or knife, is thus conducted into the blad-
 der,  and makes the  necessary  incision.-
  Some operators prefer the lithotome cache,
  which,  after being introduced,  is opened
  as far as  is deemed proper, and then drawn
  out  with its edge  turned obliquely out-
  wards and downwards.
    The  French surgeons Louis and Flu
  rant, were the invfcntors of particular bis- 
lyO                             LITHOTOMY.
  touries for dividing  both sides of  the
%female urethra at  once. *  The instrument
  of the former effected this purpose, in
  passing from without inwards; that of the
  latter, in passing from  within  outwards.
  Flurant's bistoury bears some resemblance
  in principle  to Frere Come's  lithotome
  cache*, or to the  cutting forceps,  with
  which Franco used to divide the neck of
  the bladder.   The reason, assigned in re-
  commendation of these bistouries, is, that
  they serve to make a freer opening for the
  passage of large stones, than can be safely
  made by cutting only in one direction. At
  present,  however,  they  are never used.
  Were the stone known to be very large,
  Sabatierseems to prefer the apparatus altus.
    A case may present itself, in which the
  posterior part of the bladder drawn down-
  wards by the weight of the stone,  may
  displace  a portion of the  vagina,  and
  make it protrude at the vulva in the form
  of a  swelling.. Here, there would be no
  doubt ofthe propriety of cutting into the
  tumour, and taking out the foreign body
  contained in it. Rousset performed such an
  operation.and Fabricius Hildanus in a case,
  where the stone had partly made its  way
  into the vagina,enlarged the opening, and
  successfully extracted the foreign body.
    M.  Mery  once made  the proposal of
  cutting into the  posterior part  of the
  bladder,  through  the  vagina, after intro-
  ducing a common curved staff; but the
  apprehension of urinary fistulae made him
  abandon the project.
    The existence of extraordinary circum-
  stances may always render a  deviation
  from  the common modes of operating not
  only justifiable, but absolutely necessary.
  Thus, Tolet met  with a case,  where a
  woman had  a prolapsus of the  uterus,
  with  which  the  bladder was  also dis-
  placed.  In the latter viscus, several cal-
  culi  were felt.   An  incision  was  made
  into  it, and  the  stones  extracted,  after
  which operation, the displaced parts  were
  reduced, and a  speedy  cure  followed.
  (Sabutier's Medecine Operatoire, torn. 2,p.
  107.)

      TREATMENT AFTER THE OPERATION.

    If  the internal pudental artery should
  have  been cut, and bleed profusely, the
  best plan is to introduce into the wound
  a piece of firm sponge, with a large can-
  nula passed through its centre.  The ex-
  panding  property of the sponge, on its
  becoming wet, will  make  the necessary
  degree of compression of* the vessel, which
  lies too deeply to be  tied.   The coagula
  should be washed out of the bladder, if
  they should appear to  have lodged in  it,
  by mjenting luke-warm water.
    ' I cannot sav, that it has  fallen  to my
lot to sec many  cases (out of  the  great
number  which I have seen in Bartholo-
mew's Hospital), in which death  could
be imputed to hemorrhage, notwithstand-
ing the bleeding has often been  so pro-
fuse, and from so deep a source, just after
the operation, as to leave no doubt, that
it proceeded  from the internal pudental
artery.   Such hemorrhage generally stop-
ped before the patient was put to bed.
   The majority  of patients who die after
lithotomy, perish of peritoneal inflamma-
tion.  Hence, on  the least occurrence of
tenderness over  the abdomen,  copious ve-
nesection should be put in practice.  At
the same time, eight or ten leeches should
be applied  to  the hypogastric  region.
-The belly should be  fomented, and the
bpwels kept open  with the oleum ricini.
The  feebleness  of  the pulse   should not
deter  the practitioner  from   using  the
lancet;  this symptom is only  fallacious;
and it is attendant on  all inflammation
within the abdomen.  Together with the
above measures, the warm bath, a  blister
on the lower part of the abdomen,  and
emollient  glysters, are highly proper.  I
have seen several old subjects  die of the
irritation of a diseased thickened bladder,
Continuing after the stone was extracted. I
They had not the acute symptoms, the in-
flammatory fever,  the general tenderness
and tension of the abdomen, as in cases of
peritonitis; but they referred  their unea-
siness to the lower part of tlie pelvis; and
 instead of dying in the course of  two or
 three  days, as  those  usually do,  who
 perisht of peritoneal  inflammation, they,
 for the  most part,  lingered for  two or
 three weeks after the operation.  In these
 cases,  opiate  glysters, and blistering
 the  hypogastric  region, are  the  best
 measures.  In  some  instances  of  this
 kind, abscesses form about the  neck of
• the bladder.
    Whoever wishes to acquire a perfect
 knowledge of  the history of lithotomy
 should consult the following works: Celsus
 tie Re Medicd.  lib. 7. cap. 26.   Remarques
 sur la Chirurgie de Chauliac, par M. Simon
 de Mingelouzeaux,  torn. 2;   Bourdeaux,
 1663.  La Legende du Gascon par  Drelin-
 court; Paris, 1665. Van Home's Opuscuia
 Marianus de Lapide Vesicx per Incisionem
 extrahendo; 1552. Paralleledes Differentes
 Manieres de tirer la Pierre hors de la Vessie;
 1730. Sharp's Operations.  Sharp's  Critical
 Enquiry.  Le Dr-an's Operations, Edit. 5;
 London, 1781. Franco's Traite des Hernies;
 1561.  Rosetus  de Partu Cxsario.   Traite
 de la Litholomie, par Tolet.  Heister's Sicr-
 gery,  Part 2.  Lilhotomia Douglassiana;
 1723.  Morand de alto Apparatu. Observa-
 tions sur Id Maniire de Tail/er,&c. pratiquee
 par Frere Jacques;par J. Mery. CourstTO-
perations de Chirurgie par Dionis. Traite de? 
                  LOT

Operations par Garengeot, torn. 2. Morand
Opuscules de Chirurgie.  Bertrandi Truite
den Operations.  Iiulex  SupeUectiiis  Ana-
tomicx Ravianx; Leitlx,  1725.   Le Cat,
liecueildePieces sur I'Operation delaTaille,
Part I.; Rouen, 1749.  Cosme, Recueil de
Pifces Arialomiqy.es importantes sur V Ope-
ration de la Taille;  Paris, 1751—1753. J.
Douglas,  Postscript to Hist, ofthe Lateral
Oper-ation;  1726.   Cheselden'^  Anatomy,
1730; i.ndsubsequent editions.  J. Douglas,
Appendix  to Hist, of the Lateral Operation;
1781. A sfiort Historical Account of Cutting
for the Stone, by W. Cheselden, im his own
last edition of his  Anatomy.  Falconet in
Thes. Chirurg. Halleri ; thes.  103, t. 4, p.
196.  Hartiniceil. Tractatusde Vesicx Uri-
narix calculo, &c. 1785.  Traite Historique
et Dogmatique de I' Operational la Taille par
J.F.L. Descluimps, in four tomes 8vo, Paris,
1796. This last work is a very complete and
full account of tlie subject up to tlie time of its
publication,and well merits a careful perusal.
Richerand's  Nosographie Cliirurgicale,tom.
3, p. 500, &c. Edit. 2.  Levedie's Nouvelle
Doctrine Chirurgicale, torn. 3, p. 533.  John
BelPs Principles of Surgery, Vol. 2. Part 1.
Burns, in Edinb. Med. and Surg. Journal,
January,  1808.  C. Bell's  Operative Sur-
gery, Vol. 1.  1807. Sabatier, de la Medicine
Operatoire, torn. 2,  1796.   Thomson's  Ob-
servations on Lithotomy ; Edinb. 1808.  Al-
lan's Treatise on Lithotomy ; Edinb.  1808.
Earle's Practical Observations on the Stone;
1796. Edit. 2.  (Euvres Chirurgicales de
Desault par Bichat; torn. 2.—For a minute
description and delineations of the parts
concerned in the operation, see  Camper's
Demonstration's  Anatomico -patholoricx,
Ub.2.                             S
   LOTION,  (from lavo, to wash.)  Lotio.
An external fluid  application.   Lotions
are usually  applied by wetting  linen in
them, and  keeping it  on tiie  part af-
fected.
   The following are some of the most
useful in the practice of surgery.
   LOTIO  ALUMINIS.—*.  Aluminis
purif. ^ss.  Aquae distillatae lbj. Misco.—
Sometimes used as an astringent  injec-
tion ; sometimes as an application  to in-
flamed parts.
  LOTIO AMMON1JE  ACETATiE.—
iy. Aquae  ammon.   acetatae;  Spirit, vin.
rectif.; Aquae distillatae; sing. giv. Miscev
—Properties discutient.
  LOTIO  AMMONLfi  MURIATE.—
fy. Amnion, iiiuriatae ^j.  Spirit,  rorisma-
rini lbj.—Has  the same  virtues as  toe
preceding.  Justamond recommended, it
m the early stage of the milk-breast.
   LOTIO  AMMONUE   MURIATVE
CUM ACETO.—y. Ammon. Mur. :§ss.
Aceti,  Spirit,  vinos, rectif.  sing.  Itij.
Misce. This is one of tlie most efficacious
                LOT              191

 discutient  lotions.   It is, perhaps, the
 best application for  promoting the ab-
 sorption of extravasated  blood, in cases
 of ecchymosis, contusions, sprains, &c.
   LOTIO  AMMON LE  OPIATA—9,.
 Spiritus ammon. comp. ^iiiss.  Aquae dis-
 tillatae  ^iv.  Tinct.  Opii gss. Misce.—
 Applied  by Kirkland to  some suspicious
 swellings in  the  breast, soda and bark
 being also given internally.
   LOTIO  CALCIS  COMPOS1TA.—9,.
•Aquae calcis ibj. Hydrargyri  muriati 3J.
 Misce.— Properties  strongly  astringent.
 Ring-worms,  tetters, and some other cu-
 taneous  affections yield to this applica-
 tion, which, however, should generally be
 diluted.   In the latter state, it may occa-
 sionally be used as an injection for various
 purposes.
   LOTIO  GALL^:— *. Gallarum con-
 tusarum  t^ij.  Aquae ferventis  lbj.  To
 be macerated one  hour,  and strained.—
 This astringent lotion is sometimes used
 with a view of removing the relaxed state
 of the parts,  in cases of prolapsus ani,
 prolapsus uteri, &c.
   LOTIO  HYDRARGYRI   AMYGDA-
 LINA.—%.  Amygdalarum amararum 2ij.
 Aquae distill, fbij.   Hydrarg.  mur. £j.
 Rub down the almonds with water, which
 is to be gradually poured on them; strain
 the liquor, and  then  add the  muriated
 mercury.  This will cure several cutane-
 ous herpetic affections.
   LOTIO  HYDRARGYRI   MURIATI.
 8<. Hydrargyri  muriati g.  ijss.  Arabici
 gummi gss. Aquae distillatae  ibj. Misce.
 —This is the  injection of corrosive subli-
 mate in use at St. Bartholomew's Hospital. -
    LOTIO  HYDRARGYRI  MURIATI
 COMPOSITA.—*.  Hydrarg.  mur. g. x.
 Aq. distillat.  bullientis 3iss.  Tinct. can-
 thar. 3"ss. Misce.—This was  ordered by
 Dr, H. Smith, to  be applied every night
 to scrophulous swellings.
   LOTIO HELLEBORI  ALBI— *. De-
 cocti hellebori albi tbj.  Kali sulphura-
 ri  3ss.   Misce.—This  is  occasionally
 employed as  an  application  for curing
 tinea capitis,  and  some  other cutaneous
 diseases.
    LOTIO  KALI   SULPHURATI.—j,.
 Kali sulph.  sjij.   Aqux distill, ibj. Misce
 —It is used in the same cases as the pre-
 ceding  one.
   LOTIO  LITHARGYRI  ACETATI —
 tje. Aquae litharg. acet. Jij.  Aq. distill.
 Ibij. Spirit, vinos, tenuioris 31J.  The first
 and the last ingredients are to  be mixed
 before the water is  added.
   This is the  common  whitewash,  an ap-
 plication that is so universally known as
 the usual saturnine application  in cases
 of inflammation, &c. that  we  need say
 nothing  more concerning it. 
192              L U M                               L U M
   LOTIO  OPrf.-—*. Opii  purif.  3JSS.
 Aquae distillatae tbjA Misce.—A very ex-
 cellent application to irritable painful ul-
 cers  of every  description.  It is best to
 dilute it, especially  at first.
   LOTIO  FICIS.—9t. Picis liquids  giv.
 Calcis gvj. Aquae ferventis ibhj —To be
 boiled till half the  water  is evaporated.
 The rest is then to be poured off for use.
 This  application is sometimes employed
for the cure of tinea  capitis ; it is also of
 singular service in removing an extensive
 scorbutic redness, frequently seen on the
 legs,  together with old ulcers.
   LOTItf   ZINCI   VITRIOLATI.—*.
 Zinci  Vitriolati  3j.  Aq. ferventi lbj.
 Misce.  This is sometimes used by  prac-
 titioners in lieu of the  lotio aq. litharg.
 acet.  The free  external  application of
 lead  has sometimes been  suspected of
 bringing on bad  effects, in consequence
 of absorption; and some surgeons, there-
 fore, advise the employment of this lotion
 instead  of it,  which in all probability,'
 also, is equally efficacious. When diluted,
 by adding two pints  more water, it forms
 the common injection, so  much recom-
 mended iu  cases of gonorrhoea,
   LUES VENEREA.  Venereal disease.—
 Sec this sirticlc
   LUMBAR ABSCESS.   Psoas Abscess.
 By these terms are  understood chronic
collections  of matter, which form in the
 cellular substance of the loins, behind the
peritonaeum, and descend in the course
ofthe psoas muscle.  Patients in the in-
 cipient stage ofthe disease, cannot  walk
 so well as  usual; they  feel a degree of
 uneasiness about the lumbar region; but
 in general,  there has been no acute  pain,
even  when the  abscess   has  acquired
 such a size as to form a large  tumour,
 protruding externally. In short, the psoas
 abscess  is the best  instance,  which can
possibly be adduced, in order to illustrate
 the nature  of those collections of matter,
which are called chronic, and which form
 in an insidious manner,  without; serious
 pain,  or any other attendant of acute in-
 flammation.
   The abscess sometimes forms a swelling
 jLuve Poupart's ligament;  sometimes be-
 low it; and frequently the matter glides
 under the fascia of the thigh.  Occasion-
ally,  it makes its way through tlie sacro-
ischiatic foramen, and assumes rather the
appearance of a fistula in ano.  When the
matter gravitates into the thigh, beneath
the fascia, Mr.  Hunter would have term-
ed it a disease in, not of, the part.   Tlie
 uneasiness  in the loins, and the  impulse
communicated to the tumour by coughing,
evince, that the disease arises in the lum-
 bar region ; but, it must be confessed, that
 '.v can hardly ever know the existence of
the disorder, before the tumour, by pre.
senting itself externally, leads us to such
information. The lumbar abscess is some-
times connected with diseased vertebrw,
which may either be a cause,  or an effect,
ofthe collection of  matter.—The disease,
however, is frequently  unattended  with
this complication.
  The disease of the spine, we may infer,
is not of the same  nature as  that treated
of by  Pott, as there  is usually  no paralysis.
When the bodies of patients with lumbar
abscesses  are  opened, it  is  found, that
the matter is  completely  enclosed in a
cyst, which, in many cases, is ef course,
very extensive.  If the contents of such
abscesses were not circumscribed  by a
membranous boundary in this manner, -we
should have them spreading among the
cells of the cellular substance, just  like
the water  in  anasarca.   The cysts are
both secreting and absorbing surfaces, as
is proved by the great quantity of matter,
which soon collects  again after the ab-
scess  has been emptied, and by the occa-
sional disappearance  of large  palpable
collections of matter of this kind, either
spontaneously, or in consequence of means
which are known to operate  by exciting
tlie action of the absorbents. ' In short,
the cyst becomes the suppurating surface,
and suppuration is  now well ascertained
to be  a process,  similar to glandular se-
cretion.  While the abscess  remains'un-
opened, its contents are always undergoing
a change ;  fresh  matter»is  continually
forming, and a portion of what was in the
cyst  before, is undergoing an incessant
removal  by the absorbents.   This is not
peculiar  to lumbar abscesses; it is com-
mon to alt  both chronic and acute, bu-
boes  and suppurations in general.  It is
true,  that, in acute abscesses, there often
has not been time for the formation of so
distinct a membrane as the cyst of a large
chronic abscess; but its matter is equally
circumscribed by the cavities of the cel-
lular  substance being filled with  a dense
coagulating lymph;  and  though it ge-
nerally soon makes way to the surface, it
also is occasionally  absorbed.,
  The best modern surgeons, make it a
common maxim  to open  very few acute
abscesses ; for, the  matter naturally tends
with great celerity  to the  surface of  the
body,  where ulceration allows  it to es-
cape  spontaneously;  after  which,   the
case generally goes on better,  than if it
had been opened by art.   But, in chronic
abscesses,  the matter has not that strong
tendency to make  its way outward; its
quantity is  considerably increasing;  the
cyst  is,  of course, incessantly growing
larger and larger;  in short,  the matter,
from one ounce, often gradually increases 
LUMBAR ABSCESS
193
to die quantity of a gallon.   When tlie
disease is at length opened,  or bursts by
ulceration,  the surface  of the cysts, irri-
tated by  the change,  inflames; and  its
great extent,  in this circumstance,   is
enough to account for the terrible consti-
tutional disorder, and fatal consequences,
which  too   frequently  soon follow the
evacuation of the contents of such an ab-
Bcess.  Hence, in cases of chronic suppu-
rations of every kind, and not merely  in
lumbar ones, it  is tiie surgeon's duty  to
observe the opposite rule to  that appli-
cable to  acute cases;  and he  is called
upon to open the collection of matter,   as
soon as he is aware of its existence, and
its situation will ullow'it to be done.
 . Certainly, it would  be highly advan-
tageous to have some means of ascertain-
ing whether the vertebrae are  also dis-
eased ; tor,  as in this instance, tlie morbid
bones would keep up  suppuration,  until
their affection,  had ceased,  and there
would be no  reasonable  hope of curing
the abscess sooner, it might be better  to
avoid puncturing it under such circum-
stances.  The  propriety of this conduct
teems the more obvious, as issues, which
are the means  most likely to stop and re-
move the disease of the  spine, are also
such as afford most chance of  bringing
about the absorption of the abscess itself.
However, if the collection cannot be pre-
vented from discharging itself, and  ul-
ceration  is at  hand, it is  best to meet the
danger,  make an opening with a lancet,
in a place at some distance from where
the pointing threatens,  and afterwards
heal it, in the  way we shall presently de-
tail.
  Though  we have praised tiie prudence
of opening all chronic  abscesses while
small,  the deep  situation of the lumbar
one, and the degree of doubt always  in-
volving its early state, unfortunately pre-
vent us from taking this beneficial step
in the present case.  But, still the prin-
ciple is equally praiseworthy, and should
urge us to  open the tumour as soon  as
the fluctuation of the matter is  distinct,
and  tlie  nature  of the case is  evident.
For this purpose, Mr. Abernethy employs
an abscess  lancet,  which will make an
opening large  enough for the discharge
of those  flaky  substances so  frequently
found blended  with the matter of lumbar
abscesses, and  by some conceived to be an
emblem of the disease being scrophulous.
Such flakes seem to consist of" a part  of
the coagulating matter  of the blood, and
are very commonly secreted by the pecu-
liar cysts of scrophulous abscesses.  The
puncture must also be of a certain size, to
allow the  clots of  blood,  occasionally
mixed with the  matter, to escape.   Mr.
     Vol. If.
Abernethy considers  the opening  of a
lumbar abscess, a very delicate operation.
Former surgeons used to make large open-
ings in these cases; let out the contents;
leave the wound open;  the  usual conse-
quences of which were, great irritation
and inflammation of the cyst; immense
disturbance  of the constitution;  pui re-
faction of the contents of the abscess, in
consequence of the entrance of ai